CQC report explained · a nursing home
What the CQC found at Freshford Cottage Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People were protected from abuse and avoidable harm. There were enough safely recruited staff, and medicines, infection risks and environmental risks were managed, although some employment histories were not fully recorded.
- Effective?
- Requires improvement
- The home did not always follow the Mental Capacity Act when using restrictions or making decisions for people who might lack capacity. Some newer care plans were also not in place, and lunchtime meals were served in a way that inspectors said needed improvement.
- Caring?
- Good
- This question was not inspected during this focused inspection. People said they were happy, were given choices and found staff kind.
- Responsive?
- Good
- This question was not inspected during this focused inspection. The report says people could choose activities and relatives were kept up to date.
- Well-led?
- Requires improvement
- The home had audits and a positive culture, but its systems did not reliably identify and correct gaps in care records, mental capacity paperwork and statutory notifications.
What inspectors found, March 2023
Requires Improvement; inspectors found safe, kind care but serious gaps in consent records and care planning.
This was an unannounced focused inspection on 31 January and 1 February 2023. One inspector reviewed records, medicines, care plans and audits, spoke with people, relatives, staff and health professionals, and observed care including lunchtime meals.
The home was rated Good for Safe. Inspectors found enough safely recruited staff, suitable safeguarding arrangements, safe medicines practices, good infection control and a clean environment. People said staff were kind and responded to their needs.
The home was rated Requires Improvement for Effective and Well-led. Mental capacity and best-interest decisions were not always recorded correctly, and some care plans and daily records were incomplete. The overall rating fell from Good at the previous inspection.
Safe staffing
Inspectors found enough staff to meet people's needs, with safer recruitment checks in place. People were attended to promptly.
“There were enough safely recruited staff to support people.” from the report
Safeguarding and risk
Staff understood safeguarding procedures and individual risks. Risk assessments gave staff guidance about mobility, hygiene, skin care and other needs.
“Staff understood safeguarding risks and procedures and knew what to do if concerns were raised.” from the report
Kind, person-centred care
People said they were happy, had choices and could spend their day as they wished. Relatives and staff described a positive culture.
“People were happy living at the home. They told us staff were kind, they were given choices and able to do what they liked throughout the day.” from the report
Health and nutrition support
People were supported to eat and drink, including specialised diets, and were referred to health professionals when needed. The GP contacted the home weekly about people's needs.
“People were supported to access health care professionals and services when they needed to and when their health needs changed.” from the report
Clean environment
The home was clean and tidy, with infection prevention systems and a cleaning schedule in place.
“The home was clean and tidy throughout.” from the report
Consent and mental capacity
seriousThe home did not always complete decision-specific mental capacity assessments or best-interest decisions. This included restrictions such as bed rails and decisions about shared bedrooms.
“The provider was not always following the principles of the Mental Capacity Act.” from the report
Incomplete care records
seriousSome people did not have all the required care plans, and risk assessments did not always explain how to prevent identified risks. Daily records also did not consistently show the support people needed.
“Care plans and risk assessments were not always present or contained all relevant information.” from the report
Weak governance checks
seriousAudits had identified some problems as completed, but inspectors found that improvements were still needed. Two required statutory notifications had also not been submitted when they should have been.
“The provider did not have effective systems in place to monitor and improve the quality and safety of the service.” from the report
Lunchtime meal service
minorPeople were given their main meal, dessert and hot drink at the same time. Inspectors said this could put people off eating at their own pace.
“Whilst people did not raise concerns about this it could be off putting to people as it did not encourage them to eat their meals at their own/or a leisurely pace.” from the report
- 01How have you corrected the missing mental capacity assessments and best-interest decisions, including those about bed rails and shared bedrooms?
- 02How do you now check that every person has a complete, up-to-date care plan and that risk assessments include clear prevention guidance?
- 03What changes have been made to daily living charts so staff consistently record required support, such as position changes?
- 04What action has been taken following the two missed statutory notifications, and how do you check that future notifications are submitted on time?
- 05How has the lunchtime meal service changed so people can eat their courses at their own pace?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the report says the other ratings used the previous inspection ratings to calculate the overall rating. This explanation was written from the published report of 8 March 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, March 2018
Rated Good; inspectors found safe, kind and personalised care, with further work recommended on accessible information and care plan reviews.
Inspectors visited without warning on 30 January and 1 February 2018. They spoke with people living in the home, relatives, staff and health professionals. They observed care, activities, meals and medicines, and checked care plans, records, staff files and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable training, personalised care plans, kind staff and good access to food and healthcare.
The home had improved since the previous inspection in October 2016, when it was rated Requires Improvement overall. Earlier concerns about medicines guidance, medicines records, daily records and quality monitoring had been acted on.
Inspectors recommended that the provider seek advice about the Accessible Information Standard. They also found that care plans had not always been reviewed and updated consistently, although the quality system had identified this and action was being taken.
Safe medicines
Staff had guidance for medicines given when needed. Inspectors observed medicines being given safely, with records completed appropriately.
“Staff used relevant guidance to give out 'as required' medicines safely.” from the report
Personalised care
Care plans included people's needs, preferences, life stories and risks. People and their relatives were involved in writing and reviewing them.
“The care plans were person-centred. They included people's individual support and care needs and assessment of risk; with clear guidance for staff to follow” from the report
Activities and choice
People could choose how to spend their time. Activities included group and one-to-one options and the programme could change according to people's wishes.
“People's preferences and choices were used to develop the activity programme and people spent time as they wished.” from the report
Improved oversight
The quality assurance system had improved since the previous inspection. Audits identified areas needing attention and action was taken.
“Quality assurance and monitoring systems were in place. Audits had identified areas for improvement and action had been taken to address these.” from the report
Accessible information
needs fixingStaff had not received training on the Accessible Information Standard. Inspectors recommended that the provider seek advice so staff understood their responsibilities.
“We recommend that the provider seeks advice and guidance from a reputable source, about Accessible Information Standards (AIS) to ensure staff are aware of their responsibilities.” from the report
Care plan reviews
needs fixingAn audit found that care plans had not always been reviewed and updated regularly or when people's needs changed. A staff member had been given responsibility for reviewing them.
“The audit had identified that staff had not consistently reviewed and updated these regularly or when people's needs changed, in line with the providers procedures.” from the report
- 01How do you now make sure every care plan is reviewed when a person's needs change?
- 02What action have you taken following the recommendation about the Accessible Information Standard?
- 03Have all staff received guidance or training on meeting people's communication needs?
- 04How are 'as required' medicines and their administration records checked today?
- 05How do you check that staffing levels remain sufficient for the people living here?
This was an unannounced inspection covering all five key questions, including care, medicines, staffing, the environment, records and management systems. This explanation was written from the published report of 17 March 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 Freshford Cottage Nursing Home
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Freshford Cottage Nursing Home →
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
Read what inspectors found at Freshford Cottage Nursing Home →
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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19 live-in carers within about an hour of East Sussex
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Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
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