CQC report explained · a residential care home
What the CQC found at Far Fillimore Rest Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were not always protected from abuse or avoidable harm. Risk assessments were not always followed, staffing levels were not based on assessed needs, and some safety equipment was not suitable or checked properly.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- Management and quality monitoring systems did not reliably identify risks or lead to improvement. The provider had not consistently created a learning culture.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found that safety risks were not always managed and quality checks did not reliably identify problems.
This was an unannounced focused inspection on 8 November 2023. Inspectors looked at whether the home was safe and well-led. They spoke with people, a relative, staff and a professional, observed care, and checked care, medicine, recruitment and management records.
The home was not always safe. Inspectors found unexplained bruising that had not been investigated or referred for safeguarding. Risk assessments were not always followed, falls were not always properly reviewed, staffing levels were not based on people's needs, and window restrictors were unsafe. The home was clean, but there was a strong smell in part of it.
The home was also not always well-led. Audits did not identify important safety problems or lead to enough improvement. Medicines were managed safely, people could have visitors, and the home was working within the principles of the Mental Capacity Act.
The overall rating changed from Good at the previous inspection in 2018 to Requires Improvement. CQC asked the provider for an action plan and said it would monitor progress with the provider and local authority.
Medicines
Inspectors found that medicines were stored and given safely. Records matched the stock checked, and people said they received medicines as prescribed.
“People were supported to receive their medicines safely.” from the report
Cleanliness and infection control
The home was visibly clean, cleaning schedules were in place and staff followed infection control procedures using protective equipment. There was still a strong smell in one area.
“The home was visibly clean, and we saw cleaning schedules in place.” from the report
Choice and person-centred care
People said they could choose when to get up and go to bed. Staff knew people's likes and dislikes, and the home supported people within the principles of the Mental Capacity Act.
“The registered manager and staff knew people well and knew their likes and dislikes.” from the report
Safeguarding concerns
seriousTwo people had unexplained bruising. One person said staff had caused the bruising, but the incident and bruising were not referred to the local authority for investigation.
“People were not always safeguarded from abuse and avoidable harm.” from the report
Risks and falls
seriousStaff did not always follow risk assessments. Falls and sensor mat problems were not consistently investigated or used to reduce the risk of further harm.
“Staff did not always follow people's individual risk assessments.” from the report
Staffing levels
seriousThe agreed staffing levels were not shown to be based on people's assessed needs. Inspectors found that a lack of staff was putting people at risk, particularly people who walked around or were at risk of falling.
“The lack of staff deployed throughout the home was putting people at risk of harm.” from the report
Unsafe window restrictors
seriousWindow restrictors on the top floor did not meet health and safety guidance and created a risk of falls from height. New restrictors were fitted the following day.
“We noted that the window restrictors, on the top floor of the home were not meeting health and safety guidance.” from the report
Weak quality checks
needs fixingAudits did not identify the safety problems found by inspectors. Falls, staffing and equipment problems were not analysed well enough to prevent repeat risks.
“Quality assurance systems had failed to identify the areas of concern we highlighted during our inspection.” from the report
Strong smell
minorAlthough the home was clean, inspectors found a strong smell in the ground floor bedroom area and recommended action to neutralise it.
“However, we noted a strong malodor in the ground floor bedroom area.” from the report
- 01What action has been taken to investigate and refer unexplained bruising or other possible safeguarding concerns?
- 02How are you now making sure staff follow each person's risk assessment, especially when walking or at risk of falling?
- 03How are staffing levels calculated from people's assessed needs, and what happens when several people need support at the same time?
- 04How are falls and faulty sensor mats recorded, reviewed and followed up to prevent further harm?
- 05What improvements have been made to the quality audits, window restrictors and the smell in the ground floor bedroom area?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 21 December 2023 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.
What inspectors found, March 2021
Inspected but not rated; inspectors found strong infection testing and PPE measures, but gaps in social distancing, cleaning records and risk assessments.
This was an announced, targeted inspection on 10 February 2021. It looked at infection prevention and control during the coronavirus pandemic, rather than assessing all aspects of care.
Inspectors were assured about visitor controls, safe admissions, PPE, testing and managing COVID-19 outbreaks. Staff had infection control training, and people who tested positive were supported to self-isolate.
There were also shortfalls. Social distancing was not always promoted in communal areas. Cleaning schedules and records were missing, and some risk assessments had not been documented.
The service was inspected but not rated. This means the report does not give a Good, Requires improvement or Inadequate rating for the service.
Visitor infection checks
Visitors had to have their temperature checked and take a lateral flow test before entering. Parking arrangements were also used to reduce movement and support the testing process.
“Visitors were required to have temperature checks undertaken and undergo lateral flow tests prior to entry.” from the report
PPE and staff training
Staff had infection prevention and control training and wore PPE in line with current guidance. PPE checks were completed during supervision.
“People were supported by staff who were trained in infection prevention and control (IPC) and who wore Personal Protective Equipment (PPE) in line with current guidance.” from the report
COVID-19 testing
A whole-home testing programme was in place for people living in the home and staff. People who tested positive were supported to self-isolate.
“A whole home COVID-19 testing programme was in place and people and staff were tested in line with current guidance.” from the report
Social distancing
needs fixingSocial distancing was not always promoted in communal areas. The home did not yet have a risk assessment setting out how this risk would be managed.
“Social distancing was not always promoted in communal areas.” from the report
Cleaning records
needs fixingThe home appeared clean and hygienic, but there were no cleaning schedules and cleaning was not recorded. This meant the provider could not show how often cleaning was done.
“cleaning schedules were not in place and cleaning undertaken was not recorded so the provider could not demonstrate the level and frequency of cleaning undertaken.” from the report
Missing staff risk assessments
needs fixingRisk assessments had not been documented for staff who might be at disproportionate risk from COVID-19. Risk assessments were also not recorded for staff working for other employers.
“No staff risk assessments had been undertaken to demonstrate action had been taken to mitigate risk to staff who may be at disproportionate risk of COVID-19.” from the report
- 01Have documented cleaning schedules now been introduced, and can you show how completed cleaning is recorded?
- 02What risk assessment now covers social distancing in communal areas?
- 03What actions have been taken to support social distancing when people do not follow the guidance?
- 04Have risk assessments been completed for staff who may be at disproportionate risk from COVID-19?
- 05What checks are made when staff also work for other employers, and how are infection risks managed?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide an overall quality rating or assess all aspects of care. This explanation was written from the published report of 5 March 2021 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 Far Fillimore Rest Home
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 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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