CQC report explained · a nursing home
What the CQC found at Fisher Close
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some records for medicines were incomplete, including guidance for medicines given when needed and medicine profile pages. One care plan did not clearly describe current epilepsy and dietary risks, although this was addressed during the inspection.
- Effective?
- Good
- This question was not given a rating in the report. Inspectors found that mental capacity assessments, best-interest decisions and appropriate applications for restrictions were in place or being reviewed.
- Caring?
- Good
- This question was not given a rating in the report. Staff were described as person-centred, and people were supported with their social and emotional wellbeing as well as personal care.
- Responsive?
- Good
- This question was not given a rating in the report. Person-centred guidance was in place, including plans for times when people became distressed, and people were supported to access education, communities and relationships.
- Well-led?
- Requires improvement
- Governance systems did not always identify and fix problems promptly. Audits did not consistently cover important risks, and accident and incident information was not analysed to identify patterns.
What inspectors found, December 2023
Fisher Close was rated Requires Improvement; inspectors found risks in medicines records and quality oversight.
Inspectors made an unannounced visit on 5 December 2023. One inspector spoke with people, relatives and staff, observed communal areas, and checked care plans, risk assessments, medicine records and management records.
The home was rated Requires Improvement overall. Safe was rated Requires Improvement because some medicine guidance and risk records were incomplete. Well-led was also rated Requires Improvement because quality checks did not always lead to prompt action, and accidents and incidents were not analysed well enough.
There were positive findings too. Staff knew people well, there were enough staff, the home was clean and safe, and people and relatives generally felt listened to. The provider was required to send an action plan, and CQC said it would monitor progress.
Staffing and safety
Inspectors found enough staff to meet people's needs, including one-to-one support for community access. Staff knew how to protect people from abuse and relatives said staff were available.
“The service had enough staff, including for one-to-one support for people to access the community.” from the report
Safeguarding
People were protected from avoidable harm because staff understood safeguarding responsibilities and worked with other agencies when needed.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Medicine records
seriousSome people did not have clear protocols for medicines given when needed. Medicine profile pages were also missing for some people, creating a risk of errors or unwanted effects.
“Records relating to medicine were not always in place as required to ensure people received their medicines safely and appropriately.” from the report
Incomplete risk information
needs fixingOne person's care plan did not clearly describe risks linked to epilepsy and dietary needs. Inspectors said this was addressed immediately, while other care plans were still being reviewed.
“One person's care plan was yet to be reviewed, and we found it did not contain consistent, or clear information on risks relating to epilepsy or their dietary requirements.” from the report
Weak quality oversight
seriousThe provider had identified some problems in an earlier audit but had not fully fixed them. Important areas were not always audited, and accident and incident information was not used to identify themes and trends.
“Governance systems were not effective at driving improvement. This placed people at risk of harm.” from the report
Management arrangements
needs fixingThere was no registered manager in post at the inspection. The manager was completing their CQC registration.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Have all 'as required' medicine protocols and medicine profile pages now been completed, and who checks them?
- 02How have care plans and risk assessments been updated, particularly for epilepsy and dietary needs?
- 03How are accidents and incidents now analysed to identify repeated problems or trends?
- 04What audits are now carried out for tissue viability, care plans and other key risks?
- 05Has the manager completed CQC registration, and who is responsible for oversight until then?
The report gives ratings for Safe and Well-led only; it does not give ratings for Effective, Caring or Responsive. This explanation was written from the published report of 28 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, February 2018
Rated Good overall; inspectors found safe, effective, kind and responsive care, but the home needed to improve its leadership and quality checks.
This was an unannounced comprehensive inspection on 5 January 2018. One inspector observed people and staff, spoke with staff and the manager, reviewed three care plans, and checked medicines, training, rotas, recruitment and quality monitoring.
The home supported 13 people, out of a possible 15, who had learning and physical disabilities. Inspectors found enough staff, safe medicines practice, suitable training, clean accommodation and good support with food, healthcare, activities and communication.
People were treated with kindness and dignity. Staff understood people's needs, supported their independence and helped them keep in contact with family and important people.
The overall rating stayed Good, as did Safe, Effective, Caring and Responsive. Well-led was rated Requires Improvement because provider checks, action plans and feedback systems were not always properly carried out.
Staffing had improved
Inspectors found enough staff to meet people's needs and saw staff spending individual time with people. Staffing was planned around people's needs and activities.
“At this inspection we found that improvements had been made.” from the report
Kind and respectful care
Staff understood different ways people communicated and supported them patiently, while protecting their dignity and privacy.
“People had caring, kind supportive relationships with the staff who supported them.” from the report
Personalised support
Care plans recorded people's preferences and communication methods. Staff supported choice, independence, activities and contact with family.
“People were supported by staff who knew them well and understood their preferences.” from the report
Safe medicines and risk support
Inspectors found that risks were assessed and medicines were stored, recorded and monitored so people received them as prescribed.
“Medicines were managed to ensure that people received them as prescribed.” from the report
Weak quality oversight
needs fixingProvider checks were not always completed effectively. The service manager's last audit was six months earlier, there was no action plan available on the inspection day, and some improvement actions had not been reviewed.
“This demonstrated to us that they systems for the provider to have an oversight of the quality of the service were not always effective.” from the report
Fire safety action overdue
needs fixingA fire risk assessment from March 2015 included a recommendation that had not been completed by its March 2016 deadline.
“It was recommended that the fire panel should be re-sited from the cupboard to the main entrance and this had a completion date of March 2016.” from the report
Feedback systems not in place
minorStakeholder questionnaires had not been sent out, and the questionnaires for people living at the home were not suitable. The provider was considering other ways to collect feedback.
“Therefore, the systems that the provider stated they used to gain feedback on the quality of the service were not effectively implemented.” from the report
- 01Has the fire panel been moved from the cupboard to the main entrance, and what other actions from the fire risk assessment remain outstanding?
- 02How often does the service manager now complete quality audits, and how are actions tracked to completion?
- 03What methods do you use now to obtain feedback from people who cannot complete the usual questionnaires?
- 04How do you check that staffing levels remain sufficient when people are ill or need support to go out?
- 05How are people's communication methods and care preferences kept up to date?
This was an unannounced comprehensive inspection covering all five key questions and the overall rating. This explanation was written from the published report of 10 February 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.
Every inspection of Fisher Close
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2018Goodstayed GoodSafe: GoodWell-led: Requires improvement
- November 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 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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