CQC report explained · a residential care home
What the CQC found at Firs Hall Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that safeguarding, risk management, staffing, medicines and infection control systems were in place and working. They found sufficient staff and safe recruitment records.
- Effective?
- Good
- This key question was not inspected during this targeted visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this targeted visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this targeted visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found stronger auditing, more complete records, an open culture and better oversight from the provider and manager. People and staff were involved in care reviews and improvement work.
What inspectors found, May 2022
Rated Good; inspectors found safe care and stronger management, while environmental repairs and upgrades were still ongoing.
This was a targeted inspection on 7 April 2022. One inspector spoke with people and staff, observed care, and checked care records, medicines records, recruitment files and management records. Infection prevention and control was also checked.
The home was rated Good for Safe and Well-led. Inspectors found that risks, safeguarding, staffing, medicines and infection control were managed safely. They also found better medicine recording, financial checks and oversight than at the previous inspection.
The overall rating remained Good. The other three question ratings were not checked during this visit and were carried forward from the previous comprehensive inspection.
Safe medicines management
Medicines were managed safely. Staff had medicines training and regular checks of their competence.
“Medicines records were complete and up to date.” from the report
Risks and staffing
The home assessed individual risks, kept safety checks up to date and had enough staff to meet people's needs.
“There were sufficient numbers of staff on duty at the home to ensure people's needs were met.” from the report
Improved infection control
The home acted on a previous poor infection control audit and its later score improved substantially.
“The home had scored 96% in the latest audit, with many areas showing a significant improvement.” from the report
Stronger management oversight
Inspectors found improved financial checks, better record keeping and audits covering several parts of the service.
“The provider had good oversight of all records via robust auditing systems.” from the report
Open culture and involvement
The report describes an open culture. Care plans showed that people were consulted about their care and support.
“The service embraced an open, positive and inclusive culture, led by the provider and the manager.” from the report
Environmental work still ongoing
needs fixingThe home still had an improvement plan covering environmental repairs and upgrades. Ask which repairs remain outstanding and how they are being monitored.
“The service had an on-going improvement plan, which included addressing environmental repairs and upgrades.” from the report
- 01Which environmental repairs and upgrades from the improvement plan are still outstanding?
- 02How do you check that medicines records remain complete and up to date?
- 03How many staff are normally on duty for the number and needs of residents?
- 04How are people and their families involved in reviewing care and support?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a targeted inspection of Safe and Well-led, including infection prevention and control; the other ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 11 May 2022 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, July 2021
Rated Good overall; inspectors found people were safe, but management systems needed improvement.
This was a focused inspection on 19 May and 11 June 2021. Inspectors looked only at Safe and Well-led because concerns had been raised about management and people's money. They spoke with people, relatives, staff and a visiting professional, and checked care, medicine, staff and management records.
Inspectors rated Safe as Good. People were protected from harm, staffing levels were suitable, recruitment checks were robust and medicines were generally given safely. Infection control arrangements were mostly satisfactory, although some checks and signage were missing.
Well-led was rated Requires Improvement. Medicine records were not always complete, and the provider's audits did not oversee people's finances properly. The provider gave an action plan and was asked to review both systems.
The overall rating remained Good, the same as at the previous inspection in 2018. The ratings for Effective, Caring and Responsive were not inspected and were carried forward from the earlier comprehensive inspection.
People felt safe
People and relatives told inspectors they trusted staff and felt safe. Care needs and risks were assessed and reviewed.
“People were protected from the risks of harm and people said they trusted staff to keep them safe.” from the report
Enough staff
Inspectors saw suitable staffing levels, and recruitment checks were completed before staff started work.
“There were enough staff to support people. During the inspection we observed appropriate levels of staffing to support the people who used the service.” from the report
Safe medicine administration
People generally received their medicines safely and on time. Staff were trained and had their competence checked.
“Staff had to undertake training before they could administer medicines and received regular competency checks to ensure they administered medicines safely.” from the report
Staff support
Staff said they felt supported and described good teamwork and a positive culture.
“I feel supported at work. We work great in a team; we look after all the residents and each other.” from the report
Incomplete medicine records
needs fixingRoom temperature records had gaps, and there was no consistent way to record prescribed creams. Inspectors recommended reviewing the medicine recording process.
“There were gaps in room temperature recordings and consistent systems were not being used to record the administration of prescribed creams.” from the report
Financial oversight
needs fixingThe provider's audits did not oversee people's finances, although the manager carried out financial audits. Inspectors recommended reviewing the financial auditing system.
“However, the provider's auditing systems did not have oversight of people's finances.” from the report
Relative feedback
minorThere was no formal process for collecting relatives' feedback. The home was introducing an electronic care planning system intended to include this function.
“There was no formal process to obtain relative's feedback.” from the report
Some infection control gaps
minorInspectors found no high-touch-surface checklist, no social-distancing signs and unclear areas for putting on and removing protective equipment.
“Cleaning regimes had increased, and some checklists were used, however, a specific checklist for high touch surfaces was not in place.” from the report
- 01What changes have been made to record room temperatures and prescribed creams consistently?
- 02How does the provider now check and oversee people's finances?
- 03What system is now used to collect and act on relatives' feedback?
- 04Who is currently managing the home, and what support and oversight do they receive?
- 05Have the missing infection control checks, social-distancing signs and protective equipment areas been put right?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 16 July 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 Firs Hall Care Home Limited
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- May 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Goodstayed GoodSafe: GoodWell-led: Requires improvement
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 8 December 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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