CQC report explained · a residential care home
What the CQC found at Freshfields Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2020
Rated Requires Improvement; inspectors found kind, responsive care but serious weaknesses in consent, records, recruitment and quality checks.
This was an unannounced inspection on 7 January 2020. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, staff and management records.
The home was rated Requires Improvement overall. Safe, Effective, Caring and Well-led were also Requires Improvement. Responsive was rated Good. Inspectors found that people were generally treated kindly, their care was personalised, and activities and complaints arrangements worked well.
There were important shortfalls. Mental capacity assessments and consent records were incomplete, private information was not always kept secure, some employment histories had unexplained gaps, and some mandatory training was outstanding. The home was in breach of Regulations 11 and 17.
Medicines
Inspectors found that medicines were administered by trained staff, checked regularly and audited safely.
“Medicines were managed safely.” from the report
Personalised care
Care plans included people's needs, preferences, risks, mobility, medicines and nutrition. They were reviewed with people's involvement.
“Care plans contained information about what people needed, what they liked or disliked and their risks.” from the report
Activities and communication
People had access to activities, trips and visitors. The home used pictorial and enlarged information to help people with communication needs.
“The service assessed and recorded people's communication needs and worked with other health and social care professionals to ensure they could meet those needs.” from the report
Kind interactions
People and relatives generally said staff were kind. Inspectors saw staff supporting people in a caring and unhurried way.
“We observed staff working with people and saw that they were caring and thoughtful.” from the report
Healthcare support
The home worked with a range of health and care professionals to support people's needs.
“People were supported with their health care needs and the service worked well with other professionals.” from the report
Consent and mental capacity
seriousMental capacity assessments were missing or incomplete for some people with dementia. There were no consent to care forms, so it was not always clear that care decisions had been properly agreed.
“The provider had not made sure care and treatment of service users was provided with consent of the relevant person.” from the report
Private information
seriousCare and medical information could be seen by visitors or people passing through. This included records left in public areas and keys that were accessible.
“People's information had not been maintained securely.” from the report
Risk assessments
needs fixingSome risk assessments did not consider all factors that could affect a person's risk, including relevant medical conditions.
“Risk assessments where in place did not always take into account factors that could increase or decrease risk.” from the report
Recruitment checks
seriousSome staff files had unexplained gaps in employment histories. The records did not always show risk assessments or actions relating to health conditions or positive DBS checks.
“Recruitment practices at the service were not always robust.” from the report
Staff training
needs fixingSome staff had not completed training the provider considered mandatory. This included eight care staff who had not completed infection control training.
“For example, eight care staff had not had infection control training.” from the report
- 01How have you completed mental capacity assessments and recorded consent for each person who needs them?
- 02What changes have you made to keep care plans, medical folders and other personal information secure?
- 03Have all staff now completed mandatory training, including infection control training?
- 04How do you now check employment gaps, health conditions and positive DBS results before staff work with residents?
- 05How are you checking that risk assessments are complete and that your quality audits identify problems promptly?
This was an unannounced planned inspection of the care, premises and management of the home, covering all five CQC questions. This explanation was written from the published report of 12 February 2020 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 2017
Rated Good; inspectors found kind, person-centred care, but medicine storage records and some call-bell waits needed attention.
This was an unannounced inspection on 20 June 2017. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicine charts, staff files, surveys and safety checks, and observed care.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People generally said they felt safe, respected and listened to. Care plans were detailed and reflected people's needs, preferences and goals.
Inspectors found trained staff, safe medicine administration, suitable recruitment checks and good support for nutrition and healthcare. They also found some issues, including medicine temperatures not always being recorded, a temperature that reached 27 degrees, some reported delays with the call bell at night and one complaint that was not fully resolved.
Person-centred care
Care plans included people's physical, emotional, spiritual and personal preferences. Staff were observed using this information to support people in an individual way.
“Care plans were person centred, comprehensive and reflected people's current support needs.” from the report
Kind and respectful staff
People described staff as kind and caring. Inspectors saw staff explain care, use people's preferred names and respond to comfort and personal needs.
“People told us staff were kind and compassionate.” from the report
Good staff support and training
Staff received regular training, supervision and monthly meetings. Inspectors saw evidence that training included checks of staff understanding.
“There were systems in place to ensure staff were supported to deliver evidence based care.” from the report
Strong management checks
Management was visible and approachable. Quality assurance visits, provider checks and feedback systems were used to monitor care.
“There were clear governance structures in place with a quality improvement consultant completing regular quality assurance visits to ensure systems in place were effective.” from the report
Medicine storage temperature
seriousTemperature checks for the medicine trolley were not always recorded. The temperature reached 27 degrees on the inspection day, which inspectors said was not suitable for medicines.
“However, we noted that temperature checks where the medicine trolley was kept were not always recorded.” from the report
Night-time call-bell waits
needs fixingSome people said the call bell could take longer to be answered at night. Families should ask how staffing and response times are monitored now.
“Four out of thirteen people thought there were enough staff during the day but thought it took longer for the call bell to be answered at night.” from the report
One unresolved complaint
needs fixingMost complaints had been acknowledged, investigated and answered promptly. One complaint was still not fully resolved when inspectors visited.
“We reviewed complaints and found them to be acknowledged, investigated and responded to in a timely manner with the exception of one which was yet to be fully resolved.” from the report
Privacy issue
needs fixingOne person said another person repeatedly entered their room, despite raising this with management. Staff had strategies and checks in place, but the concern remained important to that person.
“I have told the manager countless times and they say there is nothing they can do to stop her.” from the report
No formal appraisals
minorStaff had training, supervision and monthly meetings, but the home did not have a formal appraisal system at the time of inspection.
“There was no formal appraisal system in place” from the report
- 01How are medicine trolley temperatures recorded now, and what happens if the temperature becomes too high?
- 02What are the usual night-time call-bell response times, and how do you check that people are not waiting too long?
- 03How are complaints recorded and followed through until they are fully resolved?
- 04How would you protect my relative's privacy if another resident entered their room?
- 05What formal process do you now use to review staff performance and development?
This was an unannounced inspection covering all five key questions and the overall rating; the previous inspection in July 2015 was a focused inspection. This explanation was written from the published report of 14 July 2017 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 Freshfields Residential Home
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- February 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Freshfields Residential Home →
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Freshfields Residential Home →
- September 2015Goodstayed GoodSafe: Good
- March 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 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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