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Archived: Lower Farm Care Home with Nursing Inadequate

Inspection Summary

Overall summary & rating


Updated 17 August 2016

Lower Farm Care Home with Nursing provides accommodation and care for a maximum of 46 people with varying healthcare and support needs. At the time of our inspection there were 39 people living in the home. People were accommodated over two floors.

At the time of the inspection there was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

At the previous inspection in October 2015 we identified two breaches of the regulations. Improvements were needed to the quality assurance system and the care plans. The registered manager provided an action plan stating that they would take the action necessary to become compliant with the regulations by 29 February 2016. However, the system to monitor the quality of the care being provided and to drive improvement was still not effective and this impacted on all areas of the service. Work had commenced to improve the care plans so that staff had the information they required to meet people’s needs.

Risks had not always been managed to keep people as safe as possible. The necessary fire procedures were not in place to keep people safe in the event of a fire.

We could not be confident that people received their medication as the prescriber had intended. Staff competence to administer medication had not been undertaken. Current legislation was not being followed regarding the storage and recording of administration of medication. Medication audits were not being completed regularly to identify any areas for improvement.

Staff had been employed without the necessary checks being completed. Staff had not all completed the necessary training or competency assessments. This meant that people could be cared for by staff who did not have the right skills, knowledge or competency.

Staff were not always aware of the procedure to follow if they thought someone had been harmed in any way. This meant that concerns may not be investigated appropriately and the appropriate action may not be taken. There was ineffective monitoring of care and other records to assess the risks to people and ensure that these were reduced as much as possible and to improve the quality of the care provided.

The Care Quality Commission (CQC) is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was not acting in accordance with the requirements of the MCA including the DoLS. The required assessments and decisions had not been completed to ensure that people continued to be able to make as many decisions as possible. Some people may have been unlawfully deprived of their liberty.

Adequate food and drink was provided. People had access to the relevant healthcare professionals.

There were not enough staff to ensure that people always received the care and support that they needed and in a timely manner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six

Inspection areas



Updated 17 August 2016

There was not a safe system in place to ensure that the necessary recruitment checks were completed before staff commenced employment at the home.

Staffing levels were not sufficient to meet people needs in a timely manner.

Risks to people’s safety in the event of a fire were not always adequately identified or adequate action taken to reduce the risk.

Medicines were not always managed safely.


Requires improvement

Updated 17 August 2016

The service was not consistently effective.

Staff were not acting in accordance with the Mental Capacity Act 2005 including the Deprivation of Liberty Safeguards. This meant that people’s rights were not always being promoted or protected.

Staff were not receiving the support or training that they required to meet people’s needs.

People had sufficient food and drink.


Requires improvement

Updated 17 August 2016

The service was not always caring.

People’s dignity was not always upheld.

People were not always involved in the planning of their care.

Staff were seen to work in a kind and caring way for the majority of the time.


Requires improvement

Updated 17 August 2016

The service was not consistently responsive.

People were not always provided with care that was person centred and met their needs.

Not all of people’s care needs were properly planned for,

Complaints were not always recognised or responded to by the registered manager.



Updated 17 August 2016

The service was not well-led.

There was no effective quality assurance system in place to identify improvements needed and ensure that they were carried out.

The complaints system was not effective.

There were no processes in place to ensure that staff were competent to carry out their roles.