The Firs is a residential care home that was providing personal care to 24 people aged 65 and over at the time of the inspection; some of whom were living with dementia. Four people were on short stays. The home is registered for 28 people. It is owned by South West Care Homes Ltd who own and manage eight other care homes in the South West.People’s experience of using this service:
Quality assurance arrangements were weak, and problems were not always identified or addressed in a timely manner. Since our last inspection, the standard of record keeping, auditing and the safe running of the home had declined. Staff said poor quality audits of the service, a lack of investment, a lack of office time for the manager and staff vacancies were contributing factors.
Some areas of the home were poorly maintained, unsafe and odorous. Staff practice showed a lack of understanding of good infection control measures. Systems had not been put in place to ensure commode pans were emptied and washed in a safe manner to prevent the risk of cross infection. Three bedrooms had an odour of urine. Cleaning fluids had been left in two communal bathrooms and the door to the laundry and the sluice area was left unlocked which put people living with dementia at potential risk of harm. A large sofa in the conservatory had stained seat cushions.
Checks to ensure people were protected from scalds from hot water were not meaningful. When the hot water was above the recommended temperature, there was a poor audit trail to show how the risk had been managed to protect people from harm. Radiators in two bedrooms were uncovered. One person’s heavy bedroom door shut so rapidly they were in danger in being knocked over; they were frail and used a frame to walk. Neither, the door opener system or the door closure fitting were working correctly.
There were areas of the home in a poor state of repair, for example worn carpets taped to prevent a trip hazard, loose cabling, as well as chipped paintwork. There were leaks in the conservatory roof, the water dripped onto the carpet in three places and the carpet was wet. Flooring was stained or ripped around some toilets. One person’s bedroom ceiling was heavily stained due to a leak from the room above. Some bedrooms were poorly lit, which could put people at increased risk of falling.
Following the outcome of an individual safeguarding concern, action to show lessons had been learnt had not been taken promptly.
Many areas relating to care needed to be improved, including people not signing their care plans to show their agreement. There were examples of poor moving and handling by some staff. There were gaps in staff training, including medicine administration and fire safety. There was poor oversight of staff hours; one staff member was working excessive hours which had not been addressed.
Care plans and risk assessments were reviewed on a regular basis. The quality of these reviews was variable, mistakes had been made in the completion of some assessments, so they were inaccurate. However, this had not impacted on how the risk was addressed by staff.
The organisation was reviewing how peoples’ well-being and interest were met. They recognised some elements of their current provision was not suitable and were expanding the quality and choices available to people.
Staff were not recording concerns formally and therefore the complaints process was not being followed. There had been a lack of effective oversight and governance of the service, which did not support the delivery of high-quality care. The culture of the provider was not always open and transparent. People living, working and visiting the home had not been formally told of changes to the way the organisation was being run.
The provider had recruited a new team of operational staff. It was too early to see the impact of this new approach. However, since the inspection we have received timely assurances regarding action taken to address concerns.
People were positive about their experience of living at the home. They looked relaxed and at ease with staff. Staff could explain how they supported people and understood how they contributed to their health and wellbeing. For example, “I have nothing but praise for the staff, they always keep half an eye open. I can’t complain. Sometimes I need to get up quickly to the toilet, they always respond.”
Staff relationships with the people they assisted continued to be caring and supportive. People's nutritional needs were met, and people praised the quality of the food. A visitor said, “I feel the atmosphere is pleasant, they care about people.” Staff spoke confidently about the care they delivered and affectionately about the people they supported. They understood how they contributed to both people’s physical health and mental wellbeing.
Staff praised the approachability of the manager and were happy with the level of team work. They said the manager was a good role model as they were “relaxed and happy with residents.” Other staff described the manager as “kind” and “compassionate.” Staff said they enjoyed working at the home.
Rating at last inspection: Requires Improvement (report published in April 2019).
Why we inspected: This inspection was scheduled for follow up based on the last report rating.
In November 2017, a focussed inspection was completed following a safeguarding concern. The service was rated as Requires Improvement. Two previous inspections in 2016 and 2017 had been rated as Good.
In July 2018, a comprehensive inspection took place following the service becoming part of a whole service safeguarding and an individual safeguarding process. This meant the local authority safeguarding team, commissioners, CQC inspectors, police and other professionals had met to discuss the safety and well-being of the people living at the service. The provider, their operations team and the previous registered manager had been part of these discussions. Both of these alerts were closed based on the improvements and actions taken to address concerns identified. CQC are continuing to look at the circumstances surrounding an incident involving one individual.
During the inspection in July 2018, we found staff spent time with people and there was a low risk of social isolation. However, people were not always enabled to take part in meaningful activities on a regular basis. The overall rating was Requires Improvement with one breach.
In April 2019, the service was rated as Requires Improvement for a third time but this time there were no breaches.
In September 2019, there was an individual safeguarding concern raised for a person living at the home. A multi-disciplinary meeting was held, and actions were agreed to address concerns arising from the investigation.
In September 2019, a new nominated individual began working for the provider. Their role includes Director of Operations; they have a team of four staff with their own quality assurance responsibilities. These include maintenance, care planning, activities and community involvement, training and overall quality assurance. CQC have met with this new team in October 2019 and will continue to meet with them every six to eight weeks to discuss the operation and regulation of the nine homes registered with the provider.
On this inspection, we judged there had been five breaches of regulation in relation to infection control, safe care and treatment, maintenance of the building, staff training and governance arrangements. We also made a recommendation as to how oral hygiene was provided.
Special Measures
The overall rating for this service is 'Inadequate' and the service is in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement
procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Action we have taken: CQC have taken enforcement action by imposing a condition on the provider's registration. This requires the provider to provide CQC with a monthly report outlining actions and progress in making the required improvements.
Follow up: We will continue to monitor the intelligence we receive about the service. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk