Firbank House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service did not manage medicines safely because the systems and processes in place for managing medicines were not always effective. We found no evidence that people were harmed at the time of the inspection because harm is not always immediate, but people were placed at increased risk of harm because medicines were not managed safely. Accidents and incidents were reviewed however further analysis was required. Care plans were not always updated in response to accidents and incidents. Care plans did not always clearly outline people’s risks and how staff should support them safely. Appropriate health and safety checks were in place in relation to equipment at the service. There was damage to the flooring in both communal areas and people’s own rooms. This presented both a potential trip hazard and infection prevention and control issue. The concerns demonstrated a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was a fire risk assessment in place at the service. Actions had been taken in response to the fire risk assessment, however these had been completed outside of the recommended timeline given. There were records of incidents when the fire alarm had been triggered however there were no fire drills taking place at the service. Fire drills are essential and help a service test their procedures and determine any additional learning required for staff. Staff were recruited safely. Staffing levels appeared in line with the staffing dependency tool. Some staff had low training compliance. This was brought to the attention of the registered manager and addressed following our site visit.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

As care plans and risk assessments were not consistently updated following incidents at the service, improvements in people’s experience could not be demonstrated. Care plans did not demonstrate that relevant risks had been fully explored and addressed to improve people's experience.

Staff told us they completed training on a regular basis and felt this was sufficient to carry out their role. The registered manager had gathered data regarding incidents but it was unclear if this had prompted any action. The registered manager acknowledged that improvements around care planning and risk assessments were required.

Accidents and incidents were regularly reviewed by the registered manager. Analysis and improvements were not always documented in people’s care plans. For example, one person had multiple falls and their care plan did not contain clear direction for staff on how to support them and reduce their risk of falling. For another person, multiple incidents of distressed behaviour were noted but no updates to their care plan were made. Staff had completed most training. We identified 2 staff who had very low training completion rates but had worked multiple shifts at the service. We brought this to the attention of the registered manager. Following the assessment the registered manager informed us that 1 person had subsequently completed all their training and the other was almost up to date. There had been incidents of falls at the service, some of which had resulted in significant injuries for people. Not all staff had completed additional training in falls management at the time of assessment following these incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People we spoke to told us they felt safe at the service. Some people were aware when safeguarding concerns had been raised. Staff had completed safeguarding training and demonstrated good knowledge around the signs of abuse. It wasn't always clear how learning from previous safeguarding concerns had informed learning and had been shared with staff to improve people's experience.

Staff had knowledge around safeguarding and how this should be reported. The registered manager was aware of safeguarding investigations which had taken place. Following the assessment, the registered manager updated the safeguarding summary sheet to ensure that outcomes are logged with the investigation information going forward.

We observed staff treating people with kindness and respect. We observed staff supporting people to transfer in line with moving and handling guidelines.

Safeguarding policy information was available around the home. The registered manager responded to the local authority in response to safeguarding concerns being raised at the service. Safeguarding records were in place to track investigations. Supervisions showed that discussions had taken place with staff following incidents at the service. Some records lacked detail to demonstrate they directly referred to issues which had been identified.

People continued to have repeated incidents of a similar nature and care plans did not demonstrate that consideration had been given around how to reduce these risks and how to guide staff to support people. For example, a person continued to display episodes of distressed behaviour but risk assessments had not been updated and there did not appear to be any improvement in the way they had been supported by staff.

Staff told us they received information about people during handover and read the notes from the previous shift. The registered manager stated they had attended meetings about some residents prior to them moving into the home. This information was not included in their care plans which would have assisted staff in providing support.

Staff supported people with choices at the point of care. Staff supported people to transfer safely although the level of need identified was not in line with the information within their care plan.

Care plans did not demonstrate that people were always involved in managing risks. Care plans were not updated or reflective of people’s current needs. When people had fallen, it was not always evident that their care plans had been updated to reflect their need. One person’s care plan stated they used a walking stick to assist with their mobility whereas during the assessment we observed them needing the support of two staff and a wheelchair. People who had recently moved in to the service had very little information in their care plans. This information was not sufficient guidance for staff to support people safely with their needs. Risk assessments at the service were not updated and lacked sufficient information to guide staff on how to support peoples' needs safely. A review of records indicated people were not always supported in a dignified manner, and staff lacked knowledge and guidance on positive behavioural management. One person had 8 episodes of behaviours that challenge others in the last 4 months. Their risk assessment and care plan lacked a clear framework for managing behaviour that challenges others. It was also clear the way staff recorded incidents that there was a lack of knowledge as to why people displayed behaviours that challenge others.

People felt safe at the service. Some people made us aware of the issues with the flooring at the service in both bedrooms and communal areas.

Staff did not raise concerns about the environment. The registered manager and the provider were aware of hazards created by the state of the flooring around the home. At the time of the assessment, there was no clear plan in place as to when this flooring would be fixed or replaced. Staff had not been involved in fire drills at the service. Staff received information around the fire procedure during their induction at the service.

Areas of the home required improving. There was a large window in one unit which had no covering. This looked directly onto a neighbouring property and provided very limited privacy for residents. We brought this to the attention of the registered manager. Following the assessment, the registered manager informed us that a covering had now been put in place. The flooring in the dining room was coming away in parts. A temporary fix had been put in place in some areas but this had also started to come away.

The home required refurbishment to ensure flooring is safe and meets infection prevention and control measures. There were multiple areas around the home where the flooring was a potential trip hazard for people. This included both areas in people’s bedrooms and in communal areas such as the dining room. The flooring had lifted in some areas and has gaps in others. During the tour of the Windsor unit we observed the passenger lift floor hatch had steel strip exposed, this was potential trip hazard or could cause injury. However, this was made safe immediately once brought to the attention of the maintenance person. Appropriate health and safety checks had been completed at the service. There was a fire risk assessment in place at the service. Some of the actions identified on the risk assessment were not completed in the timeframe set out by the risk assessment. The service did not carry out any fire drills. The service held records of incidents when the fire alarm had sounded and action staff had taken in response. However, these were not fire drills. Care providers have a responsibility to ensure regular fire drills are completed.

We received mixed feedback from people about the staffing levels at the service. One person told us, “There aren’t enough staff though. I don’t feel at risk but you could always use more people.” Another person told us, “There are always carers around.”

Staff told us they felt there were sufficient staff available. Comments included, “Yes I feel we have enough, its rare we use agency” and “Yes I do feel we have enough staff.” Staff expressed that sometimes staffing levels can feel more pressured dependent of the needs of people on the day. Staff did not have their own staff room which meant staff breaks were taking place in communal areas with people living at the service.

Staff were mostly visible during our inspection visit and we observed they were kind and thoughtful in their interactions with people. There were times when there were no staff in the communal areas and people had to wait for support.

The provider operated safe recruitment processes. Pre-employment checks took place to ensure staff were suitable to be employed. Each member of staff provided information to demonstrate they had right to work in the UK. Relevant checks were carried out with the Disclosure and Barring Service. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The provider ensured there were sufficient numbers of suitable staff to provide care and support to people safely. The provider also completed a monthly staffing dependency tool. The minimum number of staff on duty on a daily basis is calculated using the Rhys Hearn Tool, which takes into account the number of and the level of dependency of the residents in the Home. From reviewing the dependency tool for March, April and May 2024 the calculation meets people’s assessed needs. Staff supervisions were taking place on a regular basis. Where incidents had occurred, the level of information in the supervisions, was not clear if these had been fully explored. For example, concerns around staff conduct and escalation procedures.

There were no malodours throughout the assessment. Domestic staff were on shift every day to complete cleaning tasks. People did not raise any concerns about the cleanliness of the home.

Staff felt supported to carry out their cleaning role. There was sufficient provision of domestic staff. Staff told us there were sufficient resources for them to carry out their role. Staff supported each other across the two separate units to help ensure that cleaning tasks were completed.

The service appeared clean in the areas which were used by residents. Staff wore appropriate personal protective equipment (PPE) when providing support to people.

The service appeared clean, although the condition of some flooring limited the ability for effective cleaning regimes. There was sufficient personal protective equipment (PPE) available throughout the home. Housekeepers worked at the service 7 days a week and maintained records of their cleaning schedules.

Some people were prescribed medicines which needed to be taken at specific times with regard to food. People were not always given these medicines at the correct times which mean they meant they may suffer unpleasant symptoms, or the medicines may not be fully effective. Some people were prescribed medicines to be taken ‘when required’ or with a choice of dose. The protocols to support the safe administration of these medicines were either not in place or were not personalised, and there was no information for staff to follow to assist them to administer the most appropriate dose. This meant people may not get their medicines when they were needed.

Staff did not always manage people’s medicines safely although they had received training and had been assessed as competent to so. The home manager oversaw monthly medicines audits however the audits failed to identify the concerns found during the inspection.

Records about prescribed medicines, thickeners, creams, and transdermal patches were not always properly completed so it was not possible to tell if they had been given as prescribed. Medicines, including creams and injections, were not always stored safely or at the correct temperatures.