Friars Mead

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to staff recruitment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. We requested, but did not receive, a summary of all incidents for the previous 12 months. Through review of other records, we identified some incidents, including falls resulting in fractures, which were notifiable to CQC. These notifications were not submitted; we have told the provider to do this.

Staff completed incident reports with initial actions taken. We saw these on the system but were not able to view further action taken or any learning identified. The manager told us they received an alert for all incidents, and these were shared between managers and team leaders via a messaging app and at staff handovers; it was unclear how staff not present were informed. However, staff confirmed they were told. A staff member said, “Managers keep us updated through handovers and team communication, especially if there are incidents or important changes.”

People’s relatives were informed when incidents occurred. A relative told us, “The staff on duty (day or night) have always called the family to update us on the situation and what is happening.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The manager ensured they had all the information they needed if a person was discharged from hospital. They told us, “If anyone goes into hospital, our rule is to have email discharge.” A relative said, “The management and staff were exceptional in preparing for [person’s hospital] discharge and the welcome and attention [they] received was heart-warming.”

The manager had not always worked well with healthcare partners to protect people from abuse. They did not always share concerns quickly and appropriately.

The manager described the 2 most recent safeguarding concerns. Neither of these had been reported to CQC; we told the provider to do this. Following review of other documents, we found other examples which had not been shared with us. However, we saw action was taken in response to the safeguarding concern.

The service had a safeguarding policy with contact details for the local authority. Staff were trained in safeguarding and understood their responsibilities. A staff member told us, “I do believe residents receive safe and good quality care. If something didn’t seem right, I would speak to the senior on shift or the manager straight away. If I felt it wasn’t being handled properly, I would take it further to head office, and if needed I would contact the local authority adult safeguarding team.”

The provider did not always work well with people to understand and manage risks.

People’s records did not always contain clear, consistent guidance for how to manage risks to them. For example, where people had food prepared to specific levels as per Speech and Language Therapy (SALT) assessments, we found conflicting information in people’s records as to what level they needed. Some people’s nutrition risk assessments scored them at high risk of weight loss and fluid intake; there was no guidance for staff in how to manage this. No one had food/fluid monitoring charts. This meant it was unclear how staff would identify and escalate reduced intake. However, we did not find any impact of this and a relative told us, “Carers always ensure [person] is well-hydrated and fed.”

People and their families felt people were supported by staff who understood their needs well and were happy with how risks to them were managed. A relative told us, “As a family we visit frequently and at varying times and have never seen anything which would concern us.” Another relative said, “I have always felt very reassured that [person] is in competent,professional and knowledgeable hands and receiving a high level of care.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

People were able to access all areas of the home; there were no coded entry systems to stairs or lifts. We found the accessible stairwells could present a falls risk if a person was disoriented.

The manager told us none of the people with cognitive impairment were mobile and therefore not at risk. However, we identified a person at risk of falls with no diagnosis who appeared to be experiencing cognitive decline would walk around the home. The manager told us staff spent a lot of time with this person during the day and there were regular checks overnight.

The manager’s dog was in the home on some days. There was a risk assessment for this which stated the dog was supervised at all times and included consideration of risk of falls and concluded this was low. During our visit we noted the dog dropped its toy, presenting a falls risk and noted he entered the dining room during lunch. Staff removed the dog from the area promptly and the majority of residents had no issue with the dog’s presence in the home. However, we fed back to the manager to review the risk assessment for the dog with people’s changing needs.

The manager had a refurbishment plan for the home. Where work had been done there were some holes remaining from previous fixings and where smaller extractor fans had been fitted there were some exposed wires. There was a hole in the ceiling of the medicines cupboard and some areas looked tired/cluttered. However, the refurbishment was expected to be completed by the end of the year.

The manager had not ensured staff were recruited safely to the service. We reviewed 3 recruitment records and found 2 did not have explanations for gaps in employment history, references, or police checks from their country of origin. The manager told us their policy was to gain employment history for 5/10 years. This meant their policy did not comply with the regulations which state a full employment history, together with a satisfactory explanation of any gaps in employment is required.

The manager made sure there were enough staff, who received effective support, supervision and development. They worked together well to provide care which met people’s individual needs. Staff training was monitored via a matrix and where compliance was low this had been addressed.

Staff confirmed there were enough of them, and they had the right training for their role. A staff member said, “There are always enough staff on duty on every shift: including the kitchen staff, laundry staff and housekeepers.” Another staff member told us, “In terms of training and support, I feel that the staff are well-equipped and receive the necessary training to meet individual needs effectively. There always seems to be enough staff to support people, which helps ensure that care is consistent and attentive.”

People’s relatives felt there were enough staff who understood people’s needs. A relative told us, “My experience has been that staff are very aware of [their] current physical and mental well-being and needs.” Another relative said, “There are always plenty of regular staff around which is great … consistency is key.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The manager told us there had been an outbreak of flu at the end of 2025. This had not been reported to UKHSA (UK Health Security Agency) as required. The manager told us they had support from the GP to manage this.

The home was mostly clean throughout. There was a cleaning schedule for the kitchen which did not appear to have been done when we visited, and we found room for improvement in the cleaning of some bathrooms. However, people confirmed they were happy with the cleanliness of the home. A person said, “They clean and hoover my room every day, they gave the room a full spring clean the other week. The bed is changed once a week.”

Staff confirmed they had access to enough Personal Protective Equipment (PPE).

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines as prescribed. A person told us, “The medication is on time every day and they make sure you have your medication if you go out.”

People who were prescribed medicines to be given when required (PRN), had protocols for staff to refer to so they knew when and how to administer them. We found some pharmacy labels could be clearer; staff told us they would arrange for these to be amended. Staff were able to tell us what action they would take if a person refused their medicines or errors occurred.

A person self-administered their medicines. There was a risk assessment for this which stated it would be kept in lockable storage. During our visit we noted it was on the person’s bedside table, and they did not have a lockable drawer. However, the risk assessment also noted the person’s room would be locked when the person was out and it was positive they had supported the person to maintain their independence.