CQC report explained · a nursing home
What the CQC found at Formby Manor Care 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
- Medicines were not always available or administered safely. Risk plans, handovers and some mental capacity records also needed improvement, although inspectors found enough staff, safe recruitment and good infection control.
- Effective?
- Good
- This question was not assessed during this focused inspection.
- Caring?
- Good
- This question was not assessed during this focused inspection.
- Responsive?
- Good
- This question was not assessed during this focused inspection.
- Well-led?
- Requires improvement
- Quality checks did not identify all the problems found by inspectors. Care records were sometimes incomplete, and incident reviews did not always lead to lessons being learned.
What inspectors found, August 2022
Formby Manor Care Centre was rated Requires Improvement because medicines and quality checks were not always safe or effective.
This was an unannounced focused inspection on 13 and 18 July 2022. Inspectors looked at Safe and Well-led, including medicines, staffing, records, incidents, infection control and management systems. They spoke with people, relatives and staff, and checked care, medicines and other records.
The main concerns were unsafe medicines management and weak checks on quality and safety. Some medicines were out of stock, and paracetamol-containing medicines were given without the required four-hour gap. Records and incident reviews did not always help staff learn from problems or make improvements.
There were also positive findings. Inspectors found enough staff, safe recruitment, good infection control, and a clean and well-maintained home. People and relatives were generally positive about the care, and staff said the new management team was beginning to improve staffing and communication.
The overall rating changed from Good at the previous inspection to Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Staffing
Inspectors found enough suitably qualified staff to support people safely. Staff said staffing levels had improved over the previous month.
“There were enough suitably qualified staff to support people safely.” from the report
Infection control
The home was clean and well maintained. Staff had suitable protective equipment and visitor procedures were in place.
“Measures were in place to ensure the risks of the spread of infection were reduced.” from the report
People felt safe
People and relatives told inspectors that people were safe and well looked after.
“People and relatives told us the home was safe.” from the report
Medicines
seriousMedicines were sometimes out of stock and were not always given according to prescribing instructions. This included paracetamol-containing medicines being given without a four-hour gap, creating a risk of overdose.
“Medicines were not always administered safely as per prescriber's guidance.” from the report
Quality checks
seriousThe home's audits did not identify all the concerns about medicines and records. Some care records, including fluid charts, did not accurately show the care provided.
“Quality assurance processes had failed to effectively identify and address the issues we found relating to medicines management and record keeping during this inspection.” from the report
Learning from incidents
seriousIncident reviews did not always identify patterns or make sure recommendations were put into practice. Inspectors found a similar concern after recommendations had not been implemented.
“The provider failed to ensure lessons were learnt and used to drive improvements in the quality and safety of the service.” from the report
Staff handovers
needs fixingImportant information about people's health was not always shared between staff. Inspectors were told that a person had been unwell overnight but the day staff did not know.
“Concerns with people's health or welfare were not always shared amongst the staff team.” from the report
- 01How are medicines now ordered and checked so that people do not run out?
- 02How does the new electronic medicines system prevent doses being given too close together?
- 03How do you check that fluid charts and other care records accurately show the care provided?
- 04How are incidents reviewed, and how do you make sure recommendations are put into practice?
- 05How have recent staff turnover and the skills mix on each floor been addressed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection published on 21 May 2021. This explanation was written from the published report of 23 August 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, May 2021
Formby Manor Care Home is Rated Good; inspectors found safe, kind and personalised care, with some areas still to develop.
This was the home’s first inspection since it registered in 2019. It was unannounced and took place on 20 and 21 April 2021. Inspectors spoke with people living there, relatives, staff and health and social care professionals, and reviewed records and the home’s systems.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated with respect, their risks and medicines were managed safely, and staff understood their needs and preferences.
People had a wide range of activities and support to maintain relationships and interests. Inspectors also found thoughtful end of life care and good partnership working with other professionals. The inspection was prompted partly by concerns about person-centred care, but inspectors found no evidence that people were at risk of harm from this concern.
Kind and respectful care
People and relatives gave very positive feedback about the kindness of staff. Inspectors observed caring interactions and found that people were treated with dignity and involved in their care.
“Staff knew people well and spoke about people in respectful and caring ways.” from the report
Safe systems
The home had clear risk assessments, trained staff, safe medicines systems and robust recruitment checks. Infection prevention and control arrangements were also judged satisfactory.
“Staff were aware of their responsibilities in safeguarding people from abuse. Risks were well managed.” from the report
Personalised activities
People had individual wellbeing and activity plans, with activities matched to their interests and wishes. Staff also helped people maintain contact with family and friends.
“People had access to a range of innovative and engaging activities.” from the report
End of life support
Inspectors found thoughtful and compassionate end of life care. The home worked with other professionals and supported people’s wishes wherever possible.
“The provider was thoughtful and compassionate about how they supported people receiving end of life care” from the report
Supportive leadership
Staff said managers supported them and encouraged training and development. The home used audits and feedback to identify and address issues.
“The registered manager and provider promoted a culture where staff felt valued.” from the report
Call bell response
minorOne person said they had occasionally waited longer than expected for staff to answer their call bell. This was a limited concern within an otherwise Good safe rating.
“one person who said they had occasionally had to wait longer than they expected for staff to answer their call bell.” from the report
Dementia activities
needs fixingTwo staff members felt that more could be done to involve people living with dementia in activities. This is worth discussing if it affects your relative.
“Two staff members told us that they thought more could be done to engage people from the dementia community in activities.” from the report
Mixed food feedback
minorPeople had different views about the food. One person had complained about the amount of fresh vegetables, although they had noticed some improvement.
“People shared a range of feedback about the food. It was described as 'delicious', 'excellent', 'fine' and just 'ok'.” from the report
Unresolved clothing concern
minorOne relative was not completely satisfied that a concern about clothing had been resolved, although the management team had responded.
“Just one relative told us that they were not completely satisfied that concerns about clothing had been resolved” from the report
- 01How quickly are call bells answered, and how do you check for delays?
- 02What extra activities are available for people living with dementia?
- 03How do you record and act on concerns about clothing or personal belongings?
- 04How are food preferences and requests for fresh vegetables handled?
- 05How will you keep us updated about activities and events if we do not use social media?
This was the home’s first unannounced inspection and covered all five CQC key questions, so there were no previous ratings to carry over. This explanation was written from the published report of 21 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 Formby Manor Care Home
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2021GoodSafe: GoodWell-led: Good
- July 2019
Registered with the Care Quality Commission on 19 July 2019.
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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