CQC report explained · a residential care home
What the CQC found at Faithfull House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that health, environmental and dementia-related risks were identified and managed. Medicines, staffing, recruitment and infection control were also found to be safe overall.
- Effective?
- Good
- Staff had training and support suited to people's needs, including dementia care. People were supported with food, drink, decision-making and access to health professionals.
- Caring?
- Good
- People were treated with respect and kindness. Inspectors found that privacy, dignity, communication, cultural needs and family involvement were supported.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported to take part in activities they enjoyed, maintain independence, raise complaints and receive dignified end-of-life care.
- Well-led?
- Good
- Inspectors found stronger leadership and better quality monitoring than at the previous inspection. Staff, people and relatives were included in decisions and feedback was used to improve the home.
What inspectors found, July 2018
Faithfull House is rated Good; inspectors found kind, personalised care and strong improvements since serious safety concerns in 2017.
This was an unannounced comprehensive inspection on 8 and 9 May 2018. Inspectors spoke with people, relatives and staff, reviewed care and staff records, observed care and activities, and checked medicines, complaints and quality audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that risks were identified and managed, medicines were generally handled safely, staffing levels met people's needs, and staff had suitable training.
The home had previously been rated Requires Improvement after a focused inspection in July 2017 found three breaches, including problems with managing risks and reporting incidents. At this inspection, inspectors found the required improvements had been made and all necessary regulations were met.
Improved dementia care
The separate Bluebell unit gave people living with dementia a dedicated space and a consistent team. Staff knew people's needs and triggers well and acted early to prevent distress.
“The staff on Bluebell showed very good knowledge about the people they looked after.” from the report
Kind and respectful staff
Inspectors saw staff taking time to listen, communicate patiently and support people's dignity. Relatives and people also described the care positively.
“We observed people being treated in a caring and compassionate way.” from the report
Personalised support
Care plans included people's preferences, histories and needs. Staff supported individual routines, activities and independence, including choices about where and when people spent their time.
“People's care and their daily activity was organised and tailored around their particular needs and choices.” from the report
Strong improvement in leadership
Quality checks and improvement plans had become more effective since the previous inspection. Inspectors found that these changes had led to full compliance with the necessary regulations.
“Robust quality assurance systems had resulted in improvements having been made to the service since our last inspection.” from the report
Good support with food and drink
Staff identified dietary risks and preferences and adjusted food and drinks where needed. People were offered choices and received help without being rushed.
“Mealtimes in general were relaxed affairs with no sense of rushing and many people took their time to eat and enjoy their food.” from the report
Some medicines records were incomplete
needs fixingTwo records for medicines requiring extra checks had not been completed after use. Managers investigated this during the inspection and introduced extra checks.
“Another record was required to be completed after the use of these medicines and for two medicines administered this had not been completed.” from the report
Consent records needed clarification
minorInspectors found that one document could suggest that mental capacity had been assessed for everyone's personal care. Managers agreed to review how consent was recorded.
“There had been some confusion over which document to use to record people's consent.” from the report
Bluebell environment had limitations
minorInspectors noted a short flight of stairs where gates were needed, and found the dining area cramped. Managers had started converting a bedroom into extra lounge and dining space.
“We had observed that the dining space was cramped.” from the report
- 01What extra checks are now used to make sure medicines records are completed every time?
- 02How is consent recorded now, and how do you check that mental capacity assessments are only completed when needed?
- 03Can we see the Bluebell dining area and the gated steps, and what further changes are planned for the environment?
- 04How will you make sure the staff team supporting a person with dementia remains consistent?
- 05How are relatives involved in care plan reviews and kept informed about changes in care?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 24 July 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, September 2017
Faithfull House was rated Requires Improvement; inspectors found unsafe gaps in dementia support and weak systems for managing risks and incidents.
This was an unannounced focused inspection on 20 and 21 July 2017. It followed concerns about dementia care, including staffing skills and unsafe care. Inspectors observed care, spoke with people and staff, and checked care records, call-bell records, incident records, training information and management documents.
Inspectors saw some caring support and some good practice. However, people living with dementia did not always receive prompt help when they became anxious or distressed. Behaviour plans did not always explain triggers, ways to prevent escalation or how to keep people safe.
The home’s checks did not always find poor care or ensure that incidents were reported properly. The home was also without a registered manager at the inspection, although a manager had applied for registration. The overall rating changed from Good at the January 2017 inspection to Requires Improvement, including Safe and Well-led.
Some caring support
Inspectors saw people receiving caring support from staff at some points during the inspection.
“During the inspection we observed people receiving support from staff in a caring way” from the report
Some good dementia practice
Some staff used good approaches to help people manage anxiety and agitation.
“During our inspection we observed some staff using good practice when supporting people living with dementia to manage their anxiety and agitation.” from the report
Action had started
The provider had begun recruiting staff with suitable dementia care skills and experience.
“Some actions had already started for example, the recruitment of new staff with the appropriate skills and experience to support people living with dementia.” from the report
Incomplete behaviour plans
seriousPlans did not always explain what triggered behaviour, how to prevent it escalating or how to keep people safe. This could lead to inconsistent support, especially from staff who did not know people well.
“Detailed positive behaviour support plans were not in place for people living with dementia who required consistent support from staff to identify and manage their anxiety and associated behaviour so they could remain safe.” from the report
Delayed help when people became distressed
seriousStaff were not always able to respond promptly when people became anxious or agitated. Inspectors saw situations where behaviour could have escalated and placed people at risk.
“We observed delays in people receiving support when they became anxious and agitated placing them at risk of their behaviour escalating which could harm them or others.” from the report
Weak quality checks
needs fixingThe provider’s monitoring systems did not always find shortfalls in care or ensure that improvements were made.
“The provider's monitoring systems did not always identify shortfalls in people's care so that action could be taken to make the required improvements.” from the report
Incidents were not always reported
seriousAn incident affecting a person’s safety was not reported to the manager or relevant agencies. The provider’s checks had not found this before the inspection.
“We identified the provider had not notified the CQC as required on two occasions since our last inspection.” from the report
Access to a call bell
seriousOne person was left without their pendant call bell or another way to call for help, while essential items were out of reach.
“This was not on the person and no other call bell device was available.” from the report
- 01What positive behaviour plans are now in place for people living with dementia, including their triggers and ways to prevent behaviour from escalating?
- 02How do senior staff make sure people receive prompt support when they become anxious or distressed?
- 03How are staff training, recruitment and supervision checked to ensure they can support people living with dementia safely?
- 04How are safety incidents now reported to the manager, CQC and other relevant agencies?
- 05How do you make sure every person has a working call bell or another way to call for help, with essential items within reach?
This was a focused inspection of Safe and Well-led only; the other three key questions were not assessed in this report. This explanation was written from the published report of 19 September 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Faithfull House
3 rated inspections over a year: the service has held its Good rating throughout.
- July 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2014Inspected but not rated
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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38 live-in carers within about an hour of Gloucestershire
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Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
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