CQC report explained · a residential care home
What the CQC found at The Flowers Care Home Limited
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, August 2023
The Flowers Care Home Limited is rated Requires Improvement; inspectors found that risks, medicines and quality checks were not always managed safely.
This was an unannounced inspection on 3 and 16 May 2023. Inspectors observed care, spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home was not always safe. Risks were not consistently assessed or managed. Medicines records and storage were not always safe. Staff were generally available to keep people safe, but could be stretched at times.
The home was also not consistently well-led. Daily care records were basic and quality checks did not always identify problems. Inspectors did see good hygiene, safe recruitment, prompt action from the manager when concerns were raised, and kind care from staff.
The overall rating remains Requires Improvement. The home had the same rating at its previous inspection in August 2022. It had previously been rated Inadequate in October 2021.
Infection control
Inspectors found good hygiene practices, adequate protective equipment and regular cleaning.
“People were protected by the prevention and control of infection.” from the report
Safe recruitment
The provider completed appropriate checks before staff started work.
“Staff were recruited safely. The provider carried out appropriate checks to make sure staff were suitable before they started working at the service.” from the report
Learning from incidents
Accidents were recorded and reviewed. The management team looked for patterns and ways to prevent incidents happening again.
“Accidents were well recorded and the management team reviewed individual events and identified how to prevent recurrence.” from the report
Kind staff
Although systems were inconsistent, inspectors saw staff treating people warmly and compassionately.
“Although systems did not ensure care was always person-centred, staff were observed treating people with kindness and compassion.” from the report
Risk management
seriousSome people's risks were not properly reflected in care records. Inspectors also saw unsafe moving and handling, and found environmental hazards.
“Risks to people were not always assessed and managed safely.” from the report
Medicines
seriousTopical creams were sometimes assigned to the wrong people or left unsecured. Medicine administration records and stock counts were also incomplete or incorrect.
“Medicines were not always managed safely. The service had systems and processes in place for the safe storage, administration, and use of medicines. However, these were not always implemented effectively.” from the report
Staffing pressure
needs fixingStaff were generally considered sufficient for safety, but could be stretched and focused on tasks. Some people had little stimulation for periods of time.
“At times, staff were stretched and sometimes focused on completing tasks.” from the report
Poor quality checks
seriousAudits did not always identify problems found by inspectors. Daily records also lacked important information about people's care and wellbeing.
“The lack of robust quality assurance meant people were at risk of receiving poor quality care.” from the report
Privacy and personal choice
needs fixingInspectors saw care that was not always person-centred. One person was shaved in a shared lounge instead of a private area.
“We observed one person being shaved in the lounge rather than the privacy of their room or a bathroom.” from the report
- 01What changes have you made to ensure medicines are stored correctly, given as prescribed and fully recorded?
- 02How do you now assess and monitor risks such as soft diets, moving and handling, repositioning and anxiety?
- 03What action has been taken about the loose flooring, overheated room and the shower that was out of use?
- 04How do you check that daily care records accurately describe people's routines, wellbeing and care needs?
- 05How do you make sure staffing levels and staff deployment give people enough time, attention and stimulation?
This was a focused, unannounced inspection of Safe and Well-led, prompted by concerns about staffing, risk management and medicines; ratings for the other key questions were carried over from the previous inspection. This explanation was written from the published report of 9 August 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, August 2022
Rated Requires Improvement; inspectors found important improvements, but risk records and quality checks were not yet reliable enough.
This was an unannounced focused inspection on 14 July 2022 and an announced visit on 2 August 2022. One inspector observed care, spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
The home had improved since its previous inspection. Staffing, medicines, infection control, care planning, nutrition and staff training had improved. People and relatives gave positive feedback, and staff were described as kind, skilled and familiar with people's needs.
Some problems remained. Risk assessments were not always detailed or updated after people's needs changed. There were gaps in some medicines records, and quality checks had not always found shortfalls promptly. The overall rating was Requires Improvement. The home was no longer rated Inadequate or in Special Measures, and the report says it was no longer breaching regulations.
Kind, familiar care
People and relatives gave consistently positive feedback. Staff knew people well and supported them in a calm and respectful way.
“The care is lovely. The staff are lovely.” from the report
Enough staff
The home had increased staffing levels and used a dependency tool to help assess staffing needs. Inspectors saw timely and relaxed care.
“There is more time to spend with people now.” from the report
Improved support
Care plans had improved, staff received training and people's health and nutritional needs were monitored. The home also worked with outside health professionals.
“Everything in the care plan states what people need. It is very in depth.” from the report
Better management checks
The manager had introduced audits and the home had improved its oversight since the last inspection. The provider responded to issues raised during this inspection.
“The registered manager demonstrated their commitment to ongoing improvement.” from the report
Risk records
needs fixingSome risk assessments needed more detail and were not updated promptly when people's needs changed. One person's records did not include updated information after two falls.
“some risk assessments required more detailed information and not all assessments had been updated to reflect recent changes.” from the report
Medicines recording
needs fixingMedicines were generally managed safely, but inspectors found inconsistencies and gaps in recording. The provider took immediate action after this was discussed.
“However, we continued to find there were some inconsistencies and gaps in recording.” from the report
Quality checks
needs fixingNew audits had improved oversight, but they did not always identify every shortfall quickly. The home needed to show that the improvements would last.
“We identified examples where some shortfalls had not been picked up promptly.” from the report
CCTV assessment
needs fixingCCTV was used in communal areas, but the provider had not completed a thorough assessment of whether its use was safe and appropriate, including people's rights.
“The provider had not completed a robust assessment of the safe and appropriate use of CCTV, considering the equality and human rights of people who used the service.” from the report
Involvement in decisions
minorThe home followed the legal framework for decisions made for people who lacked capacity. However, some people's involvement and views were not clearly recorded.
“some examples where a limited number of people had been involved in the decision making and their views had not always been clearly recorded.” from the report
- 01How do you make sure risk assessments are updated promptly after a fall or a change in someone's needs?
- 02What checks now make sure medicines records, including cream records and as-required medicine protocols, are complete?
- 03How do you monitor whether the improvements found at this inspection have been sustained?
- 04What assessment has been completed about the use of CCTV in communal areas and people's rights?
- 05How are people and their representatives involved in best-interest decisions, and where is this recorded?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the overall rating used earlier ratings for any key questions not inspected. This explanation was written from the published report of 10 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.
Every inspection of The Flowers Care Home Limited
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at The Flowers Care Home Limited →
- August 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Flowers Care Home Limited →
- December 2021Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- March 2015
Registered with the Care Quality Commission on 20 March 2015.
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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