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Friary Fields Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 18 August 2016

This inspection took place on 18 July 2016 and was unannounced.

Friary Fields Care Home provides accommodation for up to 34 older people and people living with dementia. 20 people were living at the service at the time of the inspection.

Friary Fields Care Home is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A registered manager was in place.

Improvements in the systems and processes to check the management of medicines were required. Protocols to advise staff about the administration of prescribed medicines to be taken as and when required were not available. Information about people’s preferences of how they took their medicines was not available for every person.

Staff were aware of their responsibilities to protect people from abuse and avoidable harm. Staff had received adult safeguarding training and had available the provider’s safeguarding policy and procedure.

Risks to people's individual needs and the environment had been assessed. Staff had information available about how to meet people’s needs, including action required to reduce and manage known risks. These were reviewed on regular basis. Accidents and incidents were recorded and appropriate action had been taken to reduce further risks. The internal environment was safe but action was required to ensure the external building was kept safe at all times.

Safe recruitment practices meant as far as possible only suitable staff were employed. Staff received an induction, training and appropriate support. There were sufficient experienced, skilled and trained staff available to meet people's individual needs.

People's healthcare needs had been assessed and were regularly monitored. The provider worked with healthcare professionals to ensure they provided an effective and responsive service. However, for one person staff had not followed recommendations from a healthcare professional and this had impacted on the person’s health.

People received sufficient to eat and drink and their nutritional needs had been assessed and planned for. People received a choice of meals and independence was promoted.

The registered manager applied the principles of the Mental Capacity Act 2005 (MCA) and Deprivations of Liberty Safeguards (DoLS), so that people's rights were protected. Where people lacked mental capacity to consent to specific decisions about their care and support, appropriate assessments and best interest decisions had been made in line with this legislation. However, these lacked specific details in places and had not been reviewed. Where there were concerns about restrictions on people’s freedom and liberty, the registered manager had appropriately applied to the supervisory body for further assessment.

Staff were kind, caring and respectful towards the people they supported. They had a person centred approach and a clear understanding of people's individual needs, routines and what was important to them.

The provider enabled people who used the service and their relatives or representatives to share their experience about the service provided.

People were involved as fully as possible in their care and support. There was a complaints policy and procedure available and people were confident to report any concerns or complaints to the registered manager. People had some information about external services that could provide support. The registered manager had information leaflets about independent advocacy services that they were going to make available for people.

People were supported to participate in activities, interests and hobbies of their choice. Staff promoted people’s independence.

The provider had checks in place that monitored the quality and safety of the service. These included daily, weekly and monthly audits.

Inspection areas


Requires improvement

Updated 18 August 2016

The service was not consistently safe

Concerns were identified with the management of medicines. Some information staff required about people’s medicines were missing or out of date. Audit systems were insufficient.

People felt safe in the home and staff knew how to identify potential signs of abuse. Systems were in place for staff to identify and manage risks and respond to accidents and incidents. The premises were safe but an external garden shed was found to be unsafe.

Sufficient staff were on duty to meet people’s needs and they were recruited through safe recruitment practices.


Requires improvement

Updated 18 August 2016

The service was not consistently effective

Communication between staff could be improved upon to ensure people’s needs were understood and acted upon.

Staff received appropriate induction, training, supervision and appraisal. People’s rights were protected under the Mental Capacity Act 2005.

People received sufficient to eat and drink. External professionals were involved in people’s care as appropriate.



Updated 18 August 2016

The service was caring

Staff were caring and treated people with dignity and respect.

People and their relatives were involved in decisions about their care.

People had some information about external services that could provide independent support. The provider had advocacy information leaflets that they were going to make available for people.



Updated 18 August 2016

The service was caring

People received personalised care that was responsive to their individual needs.

Staff had information about how to meet people’s individual needs and were knowledgeable and understood people’s routines and what was important to them.

People had access to the complaints procedure that was made available in an appropriate format for people with communication needs.



Updated 18 August 2016

The service was well-led

Staff understood the values and aims of the service. The provider was aware of their regulatory responsibilities.

People, relatives and staff were encouraged to contribute to decisions to improve and develop the service. Staff were confident in raising any concerns with the registered manager and that they would take action.

There were systems in place to monitor and improve the quality of the service provided.