The Firs Residential Care Home

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

Improvements had been made since the last inspection meaning the service was no longer in breach of any regulations; however, it is too soon to evidence these improvements had been fully embedded and sustained. People felt safe. The detail in people’s care records and risk assessments had improved. Most information was up to date and guided staff on how to assess, monitor, and support people safely. Improvements had been made to fire safety, although 2 staff were unaware of fire drills taking place. The cleanliness of the kitchen had now improved. However, we found damaged surfaces, would restrict staffs’ ability to ensure good infection control. Trained staff now understood their responsibility in keeping people safe and report concerns. However, 1 staff member was unaware of how to whistle-blow concerns. The management team now had a better understanding of the importance of skilled and knowledgeable staff required to assist people safely. Although, records did not always document the role staff would be working in for specific shifts. Most staff said they had received an induction. However, 2 staff working in high-risk areas told us they hadn't had a 'full' induction. The service currently worked with a higher level of consistent staff to the number of people accommodated. Staff completed training to meet people's needs. Supervisions were now undertaken. However, staffs’ medicines competencies were not always reviewed and dated for actions to be completed. Pre-employment checks took place on new staff. The building and facilities had undergone a programme of refurbishment, and repairs. Following incidents, staff shared learning and actions taken to reduce the risk of recurrence. Staff followed clear information when people were discharged from hospital back to the service including any additional care needs required, and health professional input. Medicines were managed safely.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was an improved culture of learning now in place. The registered manager told us, “Learning for staff needs to be a positive experience not just supervisions, talk through it [and] consider additional training. I feel it is a good team now, management team [is] always available to discuss anything.” Staff confirmed they had meetings and morning handovers where they were updated on any actions needed and discussed lessons learnt. For example, at a recent meeting, staff discussed a person’s fall, then read and signed to say they understood any actions and learning. They were also given the opportunity to ask any questions. A staff member told us, “[If] there is any immediate risk, we do lessons learnt in days, we go through trackers to analyse monthly incidents, see what happened, what went wrong. As soon as [I see the] tracker and trends and themes, I go to lessons learned, what we have learnt and in staff meeting we share with staff. [We also] ensure staff signed document to say [they] understand.”

The provider now had improved systems in place to report accidents, incidents and safeguarding’s. Actions were now taken to reduce the risk of recurrence. Staff demonstrated an improved understanding of the importance of learning from events, that occurred. Discussions were held at staff meetings to help embed learning.

People, when needed, transitioned across services. A person talked through their experience of a hospital admission and subsequent discharge back to the service. They told us of the additional care and support needed following their discharge and how health professionals would be involved.

Staff told us that when concerned about a person refusing support, they would report their concerns to the management team and the persons GP. Staff understood the importance of informing medical professionals such as the emergency services and the persons relative and or representative following an incident. A staff member said, “One resident was having significant falls, and we contacted the social worker, referred to falls [team], mental health [team and] tech enablement team.” They confirmed that sensors that alerted staff that the person, at risk of falls, was up and walking, were now in place.

The local authority shared with the CQC their most recent monitoring report of the service. Their report for adult social care accommodation-based services dated January 2024 demonstrated an overall score of good for the service.

Improvements had now been made to people’s care records and included the details and input of health and social care professionals working with the person. A lesson learnt and making staff aware document was now in place to guide staff. This document was an action because of learning following an incident. Learning was for staff to ensure ‘quick action’ was always taken as this was ‘vital in emergencies.’ It also documented that ‘calling emergency services saved time. Also, up-to-date information for families helped communicate smooth transitions between services. Clear information for staff to follow when people were discharged from hospital back to the service was now in place. This information included any additional care and support needs required, and health professional input. Since the last inspection, there have been no new admissions to the service.

People told us staff helped them feel safe as staff attended to their care and support needs. One person went on to say, “I am safe as I can be here.” Another person said, “It is very nice here.”

The registered manager when asked how they promoted safeguarding and whistleblowing amongst staff said, “[Staff] training completed, and competencies completed. We talk through this. It is everyone’s responsibility to report, including if you have concerns about me as your manager, make sure you report these concerns.” Staff said they had safeguarding training. Staff told us, “I learnt what is the term safeguarding, how I am supposed to safeguard people and myself, people are vulnerable,” and, “If I see something wrong, if in danger or harm I can report it, to make sure person is safe.” Staff’s awareness of the importance of reporting safeguarding concerns had improved. Staff knew they could report concerns to the CQC. In addition, a staff member had been given the responsibility of being safeguarding champion at the service. However, 1 staff member told us they were not aware of whistleblowing. This meant we were not assured all staff knew what to do if concerned, and how concerns should be escalated. Staff told us that The Mental Capacity Act 2005 training was mandatory. A staff member said, “It means a lack of capacity to make a decision, so we help them to make the decision easy… we assist them to make their decision like if they want to choose their clothes, they can't decide so we show them [examples].” However, another staff member showed a lack of understanding when asked a question regarding mental capacity. They replied, “Yes, we prompt fluids, high calorie meals.”

Actions were now in place to safeguard people where it has been risk assessed as needed. There was 1:1 staff support in place to keep a person safe. We observed the 1:1 staff member took immediate action when required to ensure the person’s safety. For example, when the person was sitting in an unsafe position, they guided them with patience and care. The staff member did not impose any restrictions on the persons movements around the service. Staff talked people through any health interventions. This helped ensure people understood what was happening and felt safe. We saw a visiting nurse and the staff member took the time to explain to the person why the nurse was there and made sure the person was okay.

Processes to record and monitor safeguarding concerns had now improved. However, the safeguarding log for 2024 lacked detail. The log documented 'abuse' or 'neglect' etc rather than a summary of the actual type of abuse or neglect alleged. More detailed entries on the safeguarding log would help ensure it could be used as an oversight tool to monitor and establish on-going patterns and trends. The staff training matrix dated 17 July 2024 showed and staff told us they had been trained in safeguarding the people they supported. However, the services competency checks on staff had not identified that 1 staff member was not aware of whistleblowing. Staff had training and most staff could evidence to us their understanding of best interest decisions, the mental capacity act and Deprivation of Liberty Safeguards.

People were now supported by a consistent staff team who knew them well. People and relatives felt involved and had no concerns about the care and support staff provided. Records documented and relatives told us staff involved them in reviews of their family members care decisions. People explained how staff supported them with their known risks such as being at risk of poor mobility. One person told us, “Very nice staff, they push me around [in a wheelchair] and they take me to the toilet, they do anything I want.” They went on to tell us, “No falls, no concerns.”

Staff confirmed that assessments or peoples known risks were held in the office and on the digital records system used. Staff could access these records and records were updated and reviewed monthly. Staff explained how they ensured a person, wherever possible, was involved in reviews around their care and support requirements. Staff made sure they knew the person they cared for, including the persons back history and information held in the persons care notes. Where people were unable to vocalise their wishes fully, staff told us they used people’s facial expressions to help them understand. A staff member said, “I know the residents really well, if they have a headache they will touch their head, if any pain or expressions, we administer [pain relief].’

Observations showed that staff knew people they supported well. This meant they could assess risks to people and address them. Staff encouraged fluid intake to promote good hydration, allowed people time to communicate their needs and wishes. However, not all window restrictors were of good, approved and appropriate quality. During our first site visit we found 3 windows had a chain secured by a nail as a restrictor. These could be easily broken if pressure was applied and or forced. This was reported to the registered manager who assured us this would be rectified. On the day 2 site visit all 3 had been replaced with an appropriate device.

Processes were now in place to manage risks to people. Where possible people were involved in the management of these risks. Improvements had been made to records held to guide staff around people’s known risks. People had appropriate assessments, monitoring, support and risk reducing actions in place. However, 1 person’s record stated they used [named equipment] to mobilise themselves. Daily notes documented that the person was now starting to use other equipment as they were unsteady on their feet. Whilst this change had been added to the persons personal care plan, it had not been updated in the persons mobility care plan to guide staff. This inconsistency increased the risk of staff not having up to date information. We made the management team aware, and they updated the record.

Improvements had been made to the repair and decoration of the building that accommodated people. Equipment to support people safely was in place. A person described how staff made them feel safe when using equipment to hoist them. They said, “[I’m] hoisted usually, I am not rushed, [staff] tell me, going up and going down.” However, a relative told us about the environmental improvements they felt were still needed. They said, “My [family member] had a room with a split window, it has been replaced. However, some of the windows need changing to new white windows but they are safe and secure.”

Improvements had been made to the décor of the building, facilities maintenance and repair to ensure people lived in a safe and dignified environment. The refurbishment and maintenance were on-going. The registered manager told us, “[It’s a] fantastic environment now. Calm environment and cheerful environment.” However, a staff member also told of the improvements still needed. They said, “Windows rotten.” The service is registered to accommodate 29 people. However, the shared dining room was not able to accommodate this number of people if occupancy levels increased. The registered manager told us the, “Dining room does not seat 29 [people], it seats about 16 people at the moment. [We] would use the sun lounge / conservatory for additional seating in the summer.” When asked about what they would do in the winter months they said of future plans, “We want to extend the dining room.”

Improvements had been made around the décor and repair of the building and its facilities. The refurbishment was on-going. However, the 3 unsafe window restrictors had not been identified during audits undertaken at the service. This was confirmed by the registered manager. Fire safety had now improved, with no flammable items stored under the stairs. Ongoing decorating was needed in areas of the building where walls, door frames, windowsills had some surface damage. This would ensure the surface could be cleaned without damaged areas being present which could harbour bacteria. During the first site visit we found a bedroom unlocked and unattended which contained maintenance equipment. The registered manager told us this door had been locked the day previous and was unsure why it was unlocked. This increased the risk of people having access to a high-risk area and should be secured when not occupied.

Improvements had been made around the environment and these were documented in the service improvement plan. However, areas for improvement, such as unsafe window restrictors, and chipped wooden surfaces and paintwork were still found. The window restrictor improvements needed had been identified but the service had risk assessed these safety improvements as low risk in January 2024. The action completion date of end September 2024 was recorded for a safety action that would have been a relatively quick fix. These on request of the CQC were placed during this assessment. Processes were now in place to improve fire safety. However, 2 staff were unaware of fire drills taking place. We could not be fully assured of all staff participating in drills, and or being aware of the safe precautions or action to take, in the event of the alarm activating, or a fire being found. A fire risk assessment had been carried out by an external company dated June 2024 and checks on the services utilities were undertaken.

Improvements had been made to the number of skilled and knowledgeable staff supporting people. People and a relative confirmed they had no concerns around the number of staff on duty. A person told us, “[I’ve] got a [call] bell, it does not take too long, they come as quick as they can.” Another person confirmed, “[It’s] not bad here, got a call bell, wait a few minutes, most of them [staff] are kind, none [are] horrible.” A relative told us that since the last CQC inspection, “They have upped the staffing levels.”

There were now enough skilled staff available to meet the needs of people. In the main records showed, and staff told us, there was always a staff member working at night to give ‘as required’ medicines such a pain relief when needed. However, records did not always reflect the roles staff were working in when on duty. The registered manager told us how they ensured that there were the correct skills mix of staff working each shift. They said, “Regular walk arounds and observations to ensure the right skills mix on staff.” Most staff told us they thought there was enough staff to support people safely and effectively. Staff said, “Yes we have enough staff, I work [named number of] days a week, I get breaks, half hour in morning and 30 min after lunch, enough time to do job,” and, “Yes enough staff.” However, another staff member told us, “Sometimes there could be more staff. At times, I can't spend time with people. All [staff] work incredibly hard.” Staff told us and records showed they had pre-employment checks completed to help ensure they were safe to work at the service. Most staff said they had an induction at the beginning of their employment. However, 2 new staff working in high-risk areas told us they hadn't had a 'full' induction. Staff had completed the relevant training to meet people's needs. Although not all staff could tell us their understanding of 'whistleblowing', nor their participation in fire drills. This increased the risk of staff not having gained the specific knowledge and requirements of their training.

Using the Short Observational Framework tool (SOFI) we saw 2-3 staff were present in the communal areas of the service to support people. Staff engaged with people, offered them choices, provided assurances and run activities to keep people occupied. The atmosphere was calm, and staff had time to speak to the visiting health professional and provide them with required information. Staff demonstrated they knew individual people well with how they interacted.

Improvements had been made to the number of consistent skilled and knowledgeable staff employed. The service was currently working with a higher level of staff to the number of people accommodated. This was according to the dependency tool dated June 2024 and staff rota dated 17 June, 24 June and 1 July 2024. As such, the provider and management team should monitor staffing levels when occupancy or people's needs increase. Improvements had been made to ensure the right skill mix of staff were working each shift. Most records showed, and staff told us that there was always a senior staff member on a night shift to make sure 'as required' medicines could be administered. Although the rota for the 28 June 2024 does not document a senior staff member working in this important role for the night shift. This was discussed with the registered manager, who confirmed that senior staff sometimes worked as care staff. As such, records should reflect the roles staff are working in when on duty. We saw processes were in place to make sure new staff to the service had a series of pre-employment checks completed. We saw, and most staff told us they had received an induction at the beginning of their employment. However, 2 new staff working in high-risk areas told us they hadn't had a 'full' induction. Processes at the service had not identified this. The training matrix dated 17 July 2024 showed that staff had been trained to meet the needs of people they supported. Records showed staff supervisions were now undertaken.

People and a relative told us about the cleanliness of the service and how it had improved. One person confirmed how housekeeping staff, “Dust and clean.” Whilst a relative told us, “Definitely better staff, cleaner now, I never saw the cleaner before, but this one is always around and cleaning. [The] cleanliness is better.”

Staff talked us through the training they had and how this was implemented to help control and prevent the spread of infections. A staff member confirmed, “I always use [Personal Protective Equipment] PPE. As an example, if I come to clean, I wear PPE and afterwards I put in the bin. Then I need to use new PPE in another room, sanitise my hands. After finishing our work, we have to clean and sanitise hands.”

Our observations showed that cleanliness at the service and equipment had improved. During lunch on the first site visit staff were seen encouraging people to maintain good infection control practices. It was overheard staff saying to people before lunch was served, “Would you like to wipe your hands?” Anti-bacterial cloths were also handed to people for them to use. Hand gel dispensers were now filled and working. However, during our site visit we did again find personal items left in a communal bathroom. The provider is encouraged to review this to ensure effective infection control procedures. We saw ongoing surface damage to doorframes and windowsills. This would restrict staffs’ ability to ensure effective infection control practices. We discussed this with both the registered manager and deputy manager during both of our site visits.

There had been improvements in the processes now in place to ensure the service including the kitchen followed a good standard of infection control practices. However, there was ongoing surface damage such as to doorframes and windowsills in some areas of the service. This had not been identified in the most recent health and safety audits dated 29 April 2024, or 20 May 2024. This was also not included as an improvement action required in the infection control audits evidenced dated 16 May 2024 and 07 June 2024. During this assessment we also reviewed the environmental health officer (EHO) report dated 29 November 2023. At the last inspection the CQC reported concerns to the EHO, and this was the EHO report following their visit. The actions required to improve environmental health concerns had either been completed or were on-going.

In the main people had no concerns around the safe management of their medicines by staff. We fed back to the registered manager a query a person had about the timing of their medicines with food and asked them to review this.

Staff told us they were trained to administer medicines and had their competency to do so checked. The registered manager and staff told us that trained staff were always on shift to ensure people could be supported with their prescribed medicines. This included ‘as required’ medicines such as pain relief. A staff member confirmed, “Senior staff are always on at night, and they administer any medicine needed such as pain relief medicines.”

Medicines were administered by trained staff. Only senior staff administered medicines. Staff completed annual competency assessments and medicines training. An effective communication book was in place to ensure staff remained up to date with any changes of medicines. Medicines were ordered every 4 weeks and medicines which needed to be returned were done so safely. As required medicines protocols were in place for people and reflected the prescribers’ instructions. Risk assessments were in place for people who were prescribed high risk medicines, such as blood thinning medicines. People had their medicines explained to them in a way they understood.