CQC report explained · a residential care home
What the CQC found at Friars Mead
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2020
Rated Good overall, but inspectors found the home was not consistently well-led and needed stronger management systems.
Inspectors made an unannounced inspection visit on 7 and 8 January 2020. They spoke with people living in the home, relatives, staff and managers, and checked care plans, medicines, staff records and quality audits.
The home was rated Good for safe, effective, caring and responsive care. People and relatives said they were happy, felt safe and were treated with kindness and respect. Staff supported people with medicines, personal care, health appointments, food and daily choices.
The home was rated Requires Improvement for being well-led. Management systems had improved since the last inspection, but records and audits were not always regular or effective. Activities were not always available, and the lunchtime experience could have been more engaging.
The overall rating improved from Requires Improvement at the previous inspection, published in January 2019. The home was not placed in special measures in this report.
Kind and respectful care
Inspectors saw positive relationships between staff and people. Staff respected privacy, dignity, personal routines and people's choices about where to spend their time.
“We observed positive interactions between staff and people who used the service.” from the report
Personalised support
Care plans included people's likes, dislikes, routines and preferences. People were involved in planning their care and were supported to remain as independent as possible.
“People were involved in the planning and development of their care and making choices about how they spent their time and what they were involved in.” from the report
Improved overall performance
The overall rating rose from Requires Improvement at the previous inspection to Good. Safe, effective and responsive care improved to Good, while caring remained Good.
“At this inspection we found that while some improvements had been made further improvements were required around the overall management of the service.” from the report
Management checks were not consistent
needs fixingQuality systems and records were not always regular, accurate or effective. Audits did not identify the controlled-medicine stock discrepancy, and some records did not match what was actually in place.
“Although records were established, and some systems and processes were in place. They were ad hoc and not as regular as they could be.” from the report
Activities were not always available
needs fixingThere was not always an activities staff member on duty, and care staff said they had limited time for activities. The home was trying to recruit new activities staff.
“However, we noted that there were not always activities available and there was not always activities staff on duty.” from the report
Mealtimes could be more engaging
minorMenus did not give full details of the meal choices. Inspectors found the lunchtime experience was task-driven, with too little conversation and staff interaction.
“The lunch time experience was task driven and could have been a much more pleasant experience with some background music, more conversation and staff interaction.” from the report
Staff understanding of mental capacity was mixed
needs fixingStaff had received training, but some could not clearly explain how the Mental Capacity Act applied to people in the home. The manager agreed refresher training would help.
“Staff had received training in MCA and DoLS, however staff we spoke to gave mixed responses” from the report
- 01What changes have you made to ensure quality checks are regular and identify problems promptly?
- 02How do you now check controlled medicines and investigate any recording discrepancies?
- 03How many activities are offered each week, and is an activities staff member currently available every day?
- 04What refresher training have staff received on the Mental Capacity Act and how is their understanding checked?
- 05What has changed about mealtimes, including the information shown about menu choices and staff interaction?
This was an unannounced planned inspection covering all five CQC questions, with the inspection based on the previous Requires Improvement rating. This explanation was written from the published report of 13 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, January 2019
Rated Requires Improvement; inspectors found kind care, but concerns about staffing, records, legal safeguards and activities.
The inspection was unannounced and took place on 3 October and 6 November 2018. Inspectors spoke with people living at the home, relatives, staff and managers. They reviewed three care plans, observed care and lunch, and checked records and quality checks.
People said staff were kind, respectful and caring. The home was clean, medicines were generally managed safely, and people were supported to see health professionals. However, staffing levels sometimes fell in the afternoons, some training refreshers had lapsed, and risk assessments did not always explain how risks were reduced.
Inspectors found that mental capacity assessments and applications for Deprivation of Liberty Safeguards had not been completed where needed. Care plans were not always up to date or consistent. Activities did not always meet people's interests, and people wanted more chances to go out.
The overall rating changed from Good at the previous inspection in April 2016 to Requires Improvement. Caring was rated Good. Safe, Effective, Responsive and Well-led were all rated Requires Improvement.
Kind and respectful care
People praised staff for being kind, patient and respectful. Inspectors also saw reassuring and personalised interactions.
“We saw very caring interactions between care staff and people in the home.” from the report
Privacy and dignity
Staff knocked before entering bedrooms and supported people discreetly with personal care. People were well groomed and dressed appropriately.
“People told us and our observations during the day of the inspection confirmed that people`s privacy and dignity was respected at all times.” from the report
Medicines management
Medicine records were accurate in the sample checked, and staff had training and competency checks. The report says guidance for as-needed medicines was added after the inspection.
“People's medicines were managed safely.” from the report
Safeguarding and recruitment
Staff understood how to recognise and report abuse. Recruitment checks, including references and DBS checks, were completed before employment.
“Safe and effective recruitment practices were followed to help ensure that all staff were of good character, physically and mentally fit for the roles they performed.” from the report
Handling complaints
Complaints were recorded, investigated and answered. The home used lessons from complaints to make improvements.
“Complaints were recorded and appropriately responded to in line with the provider`s policy.” from the report
Afternoon staffing
needs fixingPeople and staff said the home was sometimes short staffed, with staffing levels dropping in the afternoon even though people's needs stayed the same.
“We found that staff numbers dropped in the afternoon although people`s needs stayed the same.” from the report
Incomplete risk information
seriousRisk assessments did not always explain the measures needed to reduce risks. This included risks linked to electric wheelchairs, falls and people going outside alone.
“However, risk assessments were not always detailed or in place to give information about what measures were developed to mitigate risks and how were these reviewed.” from the report
Mental capacity and restrictions
seriousSome people with dementia had not had their decision-making ability assessed. Restrictions on leaving the building were used without the required applications being sent to local authorities.
“DoLS applications had not been submitted to local authorities although the front door required a code to open and this had not been made readily available for people.” from the report
Care records and oversight
seriousRecords were not always up to date or detailed enough to guide new or agency staff. This was a breach of Regulation 17, and the report says similar record problems had been identified at the previous inspection.
“We found the provider in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Activities and going out
needs fixingPeople had activities available, but these did not always match their interests or changing abilities. Some people wanted more opportunities to go out into the community.
“People told us that activities were provided in the home, however these were not always interesting and they wished to go out more.” from the report
Fire safety review
seriousThe registered manager completed yearly fire checks, but an external assessment had not been carried out since 2015. A further assessment was booked after the inspection.
“A fire risk assessment to assess the environment and fire procedures had not been carried out since 2015 by a qualified person.” from the report
- 01How many staff are on duty in the afternoon now, and how do you check that staffing matches people's needs?
- 02Have all people who may lack capacity had decision-specific mental capacity assessments, and have any required DoLS applications been submitted?
- 03How have care plans and risk assessments been updated since this inspection, particularly for falls, wheelchairs, hoists and people going outside alone?
- 04What activities and community outings are now available for people whose interests or abilities have changed?
- 05What was found by the external fire risk assessment, and have all its actions been completed?
This was an unannounced inspection of all five key questions, with a return visit on 06 November 2018 to review governance systems and audits that could not be accessed on the first day. This explanation was written from the published report of 9 January 2019 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 Friars Mead
3 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 23 November 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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