CQC report explained · a nursing home
What the CQC found at Fulford Care & Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found ongoing problems with medicines, staffing arrangements and management oversight.
Inspectors visited without notice on 23 and 24 May 2023. They spoke with people, relatives, staff and health professionals. They reviewed care records, medicine records, staff files and management records.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The home had enough staff according to its staffing calculations, but staff were not always deployed effectively, so people sometimes waited for care or support.
Medicines were not always stored, given or recorded safely. Some people did not always receive medicines, including pain relief, when needed. Quality checks had not reliably found or fixed these problems.
The home had improved in some areas. People were protected from abuse, infection control arrangements were satisfactory, and staff were described as kind and caring. However, the home remained in breach of regulations and the CQC requested an action plan.
Protection from abuse
Inspectors found that staff understood safeguarding responsibilities and that concerns were investigated and passed to the local authority when needed.
“People were protected from the risk of abuse and lessons were learned from incidents.” from the report
Care planning and dietary safety
Most health risks were assessed and care plans gave staff clear guidance. People with specific dietary needs were given food prepared to the correct consistency.
“We observed meals were prepared to people's correct assessed diets.” from the report
Infection prevention
Inspectors were assured about the home's infection prevention arrangements, including hygiene, protective equipment and managing outbreaks.
“We were assured the provider was responding effectively to risks and signs of infection.” from the report
Kind and person-centred care
People and relatives described staff as caring. Inspectors saw staff offering choices and responding to people's individual ways of communicating.
“Staff responded to people's needs in a person-centred way.” from the report
Listening to feedback
People, relatives and staff were invited to give feedback. Inspectors found examples of suggestions being considered and acted on.
“People and their relatives were involved and engaged by the management team.” from the report
Medicines were not consistently safe
seriousMedicines were not always stored, administered or recorded safely. Some people could wait too long for medicines, including pain relief, and risks linked to particular medicines had not always been assessed.
“Medicines were not always stored, administered and documented safely.” from the report
People sometimes waited for support
seriousStaff numbers were not always used effectively. Inspectors saw several staff taking a break at the same time, and people sometimes waited for personal care, the toilet or responses to call bells.
“The deployment of staff did not always ensure people's needs were met in a timely way.” from the report
Weak quality checks
seriousAudits and other systems had not reliably identified or fixed repeated problems. The provider remained in breach of good governance requirements.
“The provider did not always ensure continuous learning to improve the quality of care and systems in place had not identified the issues we found during the inspection.” from the report
Unsettled management structure
needs fixingThere was no registered manager during the inspection. Three managers had changed since January 2023, and senior clinical and office staff shortages affected oversight.
“There had been 3 changes of managers since January 2023 which had impacted on the oversight of the quality of care and people receiving a good service.” from the report
- 01What has been done to make sure medicines are stored, administered and recorded safely every time?
- 02How will you make sure people do not wait too long for call bells, personal care, toilet support or pain relief?
- 03Who is currently responsible for senior clinical oversight, and when will a permanent registered manager be in post?
- 04How will you check that improvements to medicines, staffing and care records are sustained?
- 05What progress has been made on the action plan requested by the CQC and the Warning Notices?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 13 July 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, October 2021
Rated Requires Improvement, with unsafe medicines, staffing shortfalls and Inadequate leadership; a warning notice was issued.
This was a focused inspection after concerns about staffing and medicines. Inspectors visited on three days, including two unannounced visits and an out-of-hours visit. They spoke with people, staff, relatives and professionals, and checked care, medicine and management records.
Inspectors found serious problems with medicines. Some prescribed medicines were unavailable, including medicines for cancer and Parkinson's. There were 58 occasions when medicines could not be given to four people, and one person went without prescribed cancer medicines for six days. Staffing was not always deployed safely or quickly enough, and people sometimes waited for care.
Leadership and checks were rated Inadequate. Audits had not found important medicine problems, and care records were not always accurate. Inspectors also found tension between staff and managers that was affecting people's wellbeing.
The overall rating fell from Good at the previous inspection in 2018 to Requires Improvement. Only Safe and Well-led were inspected at this visit. The other question ratings were carried forward from the previous comprehensive inspection.
Risk assessments
Inspectors found that risks such as choking, falls and pressure ulcers were assessed and managed. Staff used equipment safely when helping people move.
“Risks to people were assessed, and measures were taken to mitigate these.” from the report
Staff recruitment
The home carried out appropriate recruitment checks, including criminal record and professional registration checks.
“Staff were recruited safely and in line with safe recruitment guidance.” from the report
Infection prevention
Inspectors were assured about most infection prevention arrangements, including PPE, testing, cleaning and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Partnership working
The service worked with health professionals and local services to support people's health and, where appropriate, their return home.
“The service worked in partnership with healthcare professionals and services from a variety of disciplines.” from the report
People's views
Some people and relatives said they felt safe and well looked after, and relatives said their views were listened to.
“People told us they enjoyed living at the care home and felt they had been looked after very well” from the report
Medicines unavailable or given incorrectly
seriousPrescribed medicines were sometimes unavailable or not given as instructed. Inspectors found 58 missed opportunities across four people's records and one person went without cancer medicines for six days.
“There were 58 occasions between 19 June and 8 July 2021 when prescribed medicines were unable to be administered because they were not available.” from the report
Unsafe staffing deployment
seriousSome people who needed two staff were supported by one. People also waited up to 30 minutes for personal care, and the service relied heavily on agency staff.
“People who required two members of staff to safely assist them, had only received support from one member of staff.” from the report
Safeguarding failures
seriousConcerns about neglect and unsafe care were not always reported or responded to properly. Inspectors made multiple safeguarding referrals to the local authority.
“People were not always protected from harm and improper treatment.” from the report
Inaccurate care records
needs fixingCare and medicine records sometimes contradicted each other, so managers could not be sure people had received the care they needed.
“This meant the provider could not be assured people were receiving appropriate care and support to meet their needs.” from the report
Poor management oversight
needs fixingAudits and daily checks failed to identify important problems. The culture was described as task focused, with tension between staff and management affecting people.
“This is a demonstration of how the providers own processes were not effective in ensuring clinical and management oversight of people's care or for driving service improvement.” from the report
- 01What evidence can you show that every person's prescribed medicine is now available, administered correctly and checked?
- 02How do you make sure two staff are available whenever a person's care plan says two are needed?
- 03How long do people currently wait for call bells and personal care, and how is this monitored?
- 04What changes have been made to ensure care records and medicine records are accurate and agree with each other?
- 05What has been done to improve the relationship between staff and managers and to reduce reliance on agency staff?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 2 October 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 Fulford Care & Nursing Home
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2021Requires improvementSafe: Requires improvementWell-led: Inadequate
- November 2020Inspected but not ratedSafe: Inspected but not rated
- November 2018Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- March 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2016
Registered with the Care Quality Commission on 22 December 2016.
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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