CQC report explained · a residential care home
What the CQC found at Faycroft
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Only infection prevention and control was reviewed, not the whole Safe key question. Inspectors were not assured about some repairs, PPE competency records and COVID-19 test records.
- Effective?
- Requires improvement
- This key question was not assessed during this targeted inspection.
- Caring?
- Requires improvement
- This key question was not assessed during this targeted inspection.
- Responsive?
- Good
- This key question was not assessed during this targeted inspection.
- Well-led?
- Requires improvement
- Inspectors found improved governance, communication and record keeping, but the whole Well-led key question was not reviewed.
What inspectors found, October 2021
Faycroft: targeted inspection was not rated; improvements were found, but the home remained in breach and its previous rating was Requires Improvement.
This was an unannounced targeted inspection on 12 and 14 October 2021. Inspectors checked whether the provider had met a warning notice about governance and also looked at infection prevention and control.
Inspectors found better oversight, improved communication and updated care records. They saw evidence that managers were monitoring daily records, incidents and actions, and that people had more opportunities to speak with staff.
There were still concerns about parts of the building, staff confidence with putting on and removing protective equipment, and gaps in records of COVID-19 tests. The provider remained in breach because the improvements had not yet been shown to continue consistently over time.
The inspection did not give new ratings. The previous overall rating remained Requires Improvement, while Safe and Well-led were recorded as Inspected but not rated.
Improved oversight
Managers and the provider had increased monitoring of the home. Actions were recorded and reviewed at later visits.
“The overall governance of the home had increased since out last visit and there was documented evidence of provider visits.” from the report
Better care records
Care plans had been reviewed and put into a standard format. Personal safety plans were tailored to each person.
“People's care plans had been revised in line with nationally recognised guidance.” from the report
More open culture
Communication between people and staff had improved. Staff had meetings, supervision and chances to raise concerns.
“At this inspection we found the culture had improved.” from the report
People involved
Inspectors saw people making plans and talking with staff about subjects that mattered to them.
“People told us they were happy at Faycroft and we observed people having the opportunity to make plans and speak to staff about subjects which were important to them.” from the report
Repairs and hygiene
seriousSome repairs had not been completed. Worn bathroom sealant and doors needing paint could make infection prevention more difficult.
“We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
PPE competence
needs fixingStaff were observed wearing PPE correctly, but the provider could not show that all staff had been assessed as competent in putting it on and removing it.
“However, the provider could only evidence some staff had been deemed competent in the donning and doffing of PPE.” from the report
Incomplete testing records
needs fixingThere were gaps in records of COVID-19 tests, so inspectors could not be sure that everyone had taken a test. The manager said reminders had been given.
“This was because we found gaps in the records so could not be sure if all had taken a test.” from the report
Improvements not embedded
seriousThe provider had achieved compliance in the areas covered by the warning notice, but the improvements had not yet been sustained consistently.
“This is because the provider needs to embed and sustain the improvements to demonstrate consistent good practice over time.” from the report
- 01What is the timetable for repairing the worn bathroom sealant and repainting the doors?
- 02How are you checking that every staff member is competent to put on and remove PPE?
- 03How do you make sure COVID-19 test results are recorded when each test is taken?
- 04What evidence can you show that the improvements to governance and care records have been sustained since this inspection?
- 05When is the next comprehensive inspection expected, and what will be done before then to address the Regulation 17 breach?
This was a targeted inspection of specific parts of Safe and Well-led, focused on a Regulation 17 warning notice and infection prevention and control; the other key questions were not assessed and the previous ratings carried over. This explanation was written from the published report of 30 October 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.
What inspectors found, May 2021
Faycroft was rated Requires Improvement; inspectors found risks around safeguarding, medicines, consent and leadership, and issued a warning notice.
The inspection was unannounced and took place over three visits in January and February 2021. One inspector reviewed care records, staff files, risk assessments, medicines information, audits and cleaning records. They observed all six people living in the home and spoke with staff and other agencies.
The home was not always safe or effective. Risk assessments and medicine guidance were incomplete, and lessons from accidents were not always added to care plans. People's rights under the Mental Capacity Act were not consistently protected. Staff also lacked some specialist training, particularly about mental health.
People were usually treated with kindness and respect, and there were enough staff to meet people's immediate needs. However, planned one-to-one time did not always happen, and people had been exposed to a closed culture where staff did not always feel able to speak up.
The overall rating and all four rated areas were Requires Improvement. This was a deterioration from the previous Good rating, published on 17 April 2019. The provider had started an action plan, and the CQC said it would monitor progress and return to inspect.
Enough staff
Inspectors found enough staff to support people with daily tasks, activities and community access. They did not see anyone waiting for care.
“People were supported by sufficient numbers of staff.” from the report
Kind and respectful care
People were observed being treated kindly and with respect. Staff helped reduce anxiety and supported people with dignity.
“People were treated with kindness and respect during our site visit.” from the report
Everyday choices
People were supported to make informal choices about activities, going out and contacting family members.
“We saw two people asking to go out into the community and both were supported to do so and involved in decisions about where they went.” from the report
Recruitment checks
The provider carried out checks on staff applicants' character, background and qualifications.
“These checks were completed, and we could see the documentation gathered.” from the report
Safeguarding and restrictive practice
seriousStaff had previously felt unable to speak up, and guidance for physical intervention was not person-centred or clear enough. This increased the risk of unnecessary restraint or harm.
“The systems in place did not always protect people and ensure staff had the confidence to speak out.” from the report
Medicines guidance
seriousInstructions for as-required medicines were too generic. People could have received pain relief or anxiety medicine too soon, too late or not at all.
“This meant people were could be given their medicine either too soon, too late or not at all.” from the report
Consent and best interests
seriousMental Capacity Act assessments and best-interest decisions were not consistently clear or properly supported. Care records did not show people's views or the involvement of others.
“This meant people were at risk of being excluded from formal the decision-making process.” from the report
Closed culture and weak oversight
seriousThe provider's systems did not identify important problems, and concerns raised in supervision were not escalated. The provider was still reviewing practices that could be restrictive.
“Evidence of poor leadership was found.” from the report
Missed one-to-one sessions
needs fixingSome people were meant to have weekly 'my time' sessions, but inspectors could not find evidence that these had happened in recent months.
“This meant people may not of had the opportunity to confide in staff if they were having issues.” from the report
- 01What changes have been made to risk assessments, including risks linked to diabetes and other health conditions?
- 02How do staff now receive clear, person-centred guidance about physical intervention and as-required medicines?
- 03How are Mental Capacity Act assessments and best-interest decisions completed, and how are families and professionals involved?
- 04How does the home make sure weekly 'my time' sessions and other care-plan commitments actually happen?
- 05What evidence can you show that the warning notice and the action plan have been addressed?
This was a focused inspection prompted by concerns about harm, risk, leadership and culture; it rated Safe, Effective, Caring and Well-led, while Responsive was not rated in this report. This explanation was written from the published report of 7 May 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 Faycroft
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- October 2021Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- May 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- April 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
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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