CQC report explained · a nursing home
What the CQC found at Finch Manor Nursing Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, April 2024
Finch Manor Nursing Home was rated Inadequate and remains in special measures; inspectors found serious, repeated failures that put people at risk of avoidable harm.
This was an unannounced comprehensive inspection over three days. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, staff files and records about the running of the home.
Inspectors found serious problems with care, medicines, staffing and risk management. People's needs were not reliably assessed or met. Accidents and care failures were repeated. Some people waited a long time for help, and clinical care was poorly delivered.
The home was rated Inadequate in all five areas: Safe, Effective, Caring, Responsive and Well-led. The overall rating was unchanged from the previous inspection. The report says the home remains in special measures because significant improvements are needed.
Cleaner environment
Inspectors found that the home was adequately clean during the visit. Cleaning schedules and protective supplies were in place.
“During our visit the home was adequately clean.” from the report
Visitors welcomed
People could have regular visitors, and inspectors saw that visitors were welcomed into the home.
“People were able to have regular visitors and we saw that visitors were welcomed into the home.” from the report
Insufficient staffing
seriousInspectors found that staffing levels were not safe or sufficient, particularly at night. The heavy use of agency staff also meant staff did not always know people's needs.
“Not enough staff were on duty to meet people's needs and keep them safe.” from the report
Poor clinical care
seriousWounds, catheters, continence, nutrition and other health needs were not consistently assessed, treated or monitored. This left people at risk of avoidable harm.
“Wound management was inadequate. People's wounds were not assessed or cared for appropriately to prevent further skin breakdown or infection.” from the report
Dignity not protected
seriousInspectors saw people left in undignified or uncomfortable situations, including one person left with wet food on their clothing and another left with their door open while undressed.
“Another person sat for 20 minutes with wet food all down their front at lunchtime, before any action was taken by staff to help them change.” from the report
Limited activities and personalisation
needs fixingPeople had little meaningful activity and were often left in lounges or bedrooms. Care plans did not consistently reflect people's needs and preferences.
“There was little in the way of any meaningful activities for people to engage with.” from the report
Weak management oversight
seriousAudits identified repeated failings, but managers and the provider did not take robust action to stop them happening again. The manager in post was not registered with CQC at the time of inspection.
“The systems in place to monitor the quality and safety of the service were not effective.” from the report
- 01What immediate changes have been made in response to the urgent action plan?
- 02How are you now checking that medicines, insulin and time-sensitive medicines are given safely and on time?
- 03What staffing levels are provided on each shift, especially at night, and how do you check agency staff understand each person's needs?
- 04How are care plans and risk assessments being reviewed for wounds, nutrition, fluids, continence, repositioning and choking risks?
- 05How are mental capacity assessments, best-interest decisions and consent being recorded and followed?
This was an unannounced comprehensive inspection covering all five key questions, including the premises and care provided; all five ratings remained Inadequate. This explanation was written from the published report of 4 April 2024 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, August 2023
Finch Manor Nursing Home was rated Inadequate and remains in special measures; inspectors found widespread risks and poor leadership across all five areas.
Inspectors visited unannounced on four days in February 2023. They spoke with 12 people and 15 staff, and checked care, medicine and management records. The inspection was prompted partly by concerns about staffing, management and care quality.
The home was not consistently safe. Risks were not properly assessed, medicines and infection control were not always managed safely, and staffing arrangements were unreliable. Some records were incomplete or contradictory, and staff did not always know people's needs, choices or dietary requirements.
People were not always treated with dignity or involved in decisions. Care was not consistently personal or responsive, and the home did not have effective leadership or checks to identify and fix problems. All five ratings were Inadequate.
The home had been in special measures since 19 January 2023 and remained Inadequate at this inspection. The report says some action was taken during the inspection to address the most serious risks, but not enough improvement had been made overall.
Safeguarding reporting
The home had improved how it recorded and reported safeguarding concerns. CQC said it was no longer in breach of the safeguarding regulation.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 13.” from the report
Medicine training
Medicine administration records had been signed, and staff who administered medicines had completed training and competency checks.
“Staff responsible for the administration of medicines had completed medicines training and had their competency checked.” from the report
Healthcare access
People could access regular GP and other healthcare support. However, advice from healthcare professionals was not always added to care plans.
“GP services and associated health care professionals visited the service on a regular basis to monitor people's health.” from the report
New management team
A new manager and support team had recently joined and had identified areas needing improvement.
“A new manager and support team had recently been employed at the service.” from the report
People were at risk
seriousRisk assessments and safety checks were incomplete or ineffective. A nurse call bell was not working in one area, and fire exits were blocked.
“People's needs were at risk of not being met. In one area of the service the nurse call bell sounder system was not working.” from the report
Insufficient and inexperienced staffing
seriousThe home relied heavily on agency staff, including staff who did not have enough guidance about people's needs. Records did not always show that recruitment checks had been completed.
“People were not supported by a sufficient number of experienced and supported staff.” from the report
Poor cleanliness and infection control
seriousSome areas and equipment were visibly dirty. Food was undated or out of date, and communal areas were used to store equipment and waste products.
“Areas of the service were visibly unclean. Small kitchen areas had a buildup of debris on equipment, surfaces and floors.” from the report
Food and drink support
seriousStaff did not always know people's dietary needs or provide the support and encouragement they needed to eat and drink. Meals were sometimes left to go cold.
“People were not always supported to eat and drink enough. For example, people requiring encouragement to eat their meals were given no encouragement or other alternative foods were not offered.” from the report
Dignity and privacy
seriousPeople were not always treated respectfully or involved in choices. Care documents were left where others could see them, and most bedrooms did not have usable privacy locks.
“People had not always been treated or spoken to with dignity and respect.” from the report
Poor records and oversight
seriousCare and staffing records were not reliable enough to show what support people needed or had received. Management checks failed to identify problems found by inspectors.
“Records relating to people were not fit for purpose and put people at serious risk of not receiving the care, treatment and support they needed.” from the report
- 01What has been done to make sure nurse call bells work in every area, and how is this now checked?
- 02How do you ensure agency and newly recruited staff know each person's care, communication and dietary needs before providing support?
- 03What action has been taken to improve cleanliness, food storage and infection control in the small kitchens, bathrooms and sluice rooms?
- 04How are people's care plans, risk assessments, nutrition records and Mental Capacity Act decisions now checked for accuracy and completeness?
- 05What evidence can you show that the new management team has fixed the problems identified in this inspection?
This was an unannounced focused inspection prompted by concerns about staffing, management and care quality, and it also checked infection prevention and control; inspectors reported ratings for all five key questions. This explanation was written from the published report of 17 August 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.
Every inspection of Finch Manor Nursing Home
7 rated inspections over 5 years: the service has slipped, from Requires improvement to Inadequate.
- April 2024Inadequatecurrent ratingstayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- August 2023Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- February 2023InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2022Inspected but not ratedSafe: Inspected but not rated
- May 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- September 2020Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- October 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- March 2018
Registered with the Care Quality Commission on 14 March 2018.
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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