Frindsbury House

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems were in place to protect people from the risk of abuse. When incidents of concern happened, management took immediate action to investigate and safeguard people. Not all staff members had always reported safeguarding concerns at the time these occurred. However, when the management team became aware of issues, they acted in people’s best interests to address and mitigate any risks. Following a recent safeguarding concern all staff had undertaken training and told us they felt confident to raise concerns with the management team.

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.

Systems were in place to support people when they moved between services, including for example if they were to go into hospital. A healthcare professional told us the manager supported them to advocate for a person who had been placed at an inappropriate setting. The manager and professional worked together to advocate for the person and support them to move into Frindsbury House. The healthcare professional told us that this had a huge impact on the person, whose life had improved greatly.

Relatives gave us positive feedback about the transition to the service. One told us, “He was in another home before, it was awful, there’s been no looking back.”

Although staff had received safeguarding training, we found they did not always report and escalate safeguarding concerns when they occurred. When the provider was made aware of safeguarding concerns, they took immediate action to safeguard people. Following safeguarding incidents, the provider reviewed recruitment processes, policies, and staff practices as well as ensuring all staff re completed safeguarding training. When the provider was aware of safeguarding concerns, these were always shared with the local authority safeguarding team.

Relatives we spoke with told us people were safe at Frindsbury House. Comments included, “I think she feels safe,” and “It’s lovely and nice to see who she trusts.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the service was working within the principles of the MCA.

Some risks to people had not been identified and mitigated. For example, thickening powders had not always been stored appropriately. Thickener is a substance used to change the consistency of a fluid, to support people who have difficulties swallowing, and if digested could cause someone to choke. When we raised this with leaders, immediate action was taken to address this.

Some care plans and risk assessments were not up to date and reflective of people’s needs. For example, 1 person’s care plan stated that they were able to mobilise with a walking aid. This was no longer the case, and the care plan had not been updated. Another person’s constipation care plan was not up to date which could cause staff not to take the correct action if the person became unwell. Leaders were aware that care plans needed reviewing and updating and put an action plan in place to address this.

People’s risks were known by staff, and people were supported to take positive risks. For example, 1 person was at risk of choking but chose to eat a diet that did not follow guidance from a health professional. The provider implemented measures to support the person as safely as possible whilst upholding the person’s right to make choices.

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.

Personal emergency evacuation plans (PEEP) were not always up to date and did not reflect any recent changes to an individual's condition. One person’s PEEP was dated 18 May 2023, and had noted that the individual required walking aids on evacuation. However, on it was noted this person now needed to use a wheelchair. This presents a potential risk should someone who does not know the individual use the PEEP in the event of an emergency. Following the inspection the provider told us that they would review all PEEPs in place to ensure they were reflective of people’s needs.

People had the equipment they needed to support them to remain safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were supported by sufficient numbers of skilled staff. Staff were very knowledgeable of people’s individual needs, risks and concerns. Staff had received the training they needed to support people safely. A healthcare professional told us, “No concerns regarding staff training- they all appear to have an excellent approach and have always answered any questions or directed me to someone if they do not know.” A relative told us, “In regard to safety I’m very confident in staff, as far as I know they’re safe with manual handling, using hoisting.”

Relatives told us there was enough staff. One told us, “I would say when I’ve been there it is ok.” Staff told us, “I feel that there are enough staff at the home and we try to utilise their strengths and weaknesses to balance the care given.” A healthcare professional told us, “I find the carers some of the best I've come across.”

Recruitment processes were followed to ensure staff were suitable to support people, including use of Disclosure and Barring Service (DBS) checks. A DBS check is a criminal record check used by employers to help them make safer staffing decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and free from malodours. People and relatives gave positive feedback about the cleanliness of the service. Relatives told us, “No concerns, absolutely not, it’s spotless,” and “It smells nice in there,” and “It’s immaculate.” We observed staff wearing appropriate personal protective equipment (PPE) when supporting people.

The provider had not ensured medicines were always well managed.

The provider failed to ensure prescribed thickener was being used appropriately. We found 5 people were prescribed thickener. However, we found that only 2 people had thickener in the cupboard in the dining room where drinks were prepared for people. We also found open tubs of thickener in the medicines trolly with the prescription label removed and no name. We could not be assured that thickener was not being shared between people or how much was being used for each serving. Some people were prescribed medicated creams. Staff did not always document the application of this within their medicine administration record (MAR) which meant it was not always clear if the cream had been administered. We raised this with leaders, and actions were taken to address these concerns.

Other aspects of medicines administration were appropriately managed. For example, when people had ‘as and when’ medicines for example paracetamol for pain relief, processes were followed appropriately including documenting why the medicine was administered. We found that MAR’s were fully completed, demonstrating people had received their medicines as prescribed. Staff understood their responsibilities in relation to ‘STOMP’ and applied this where appropriate. STOMP aims to Stopping Over Medication of People with a learning disability and/or autistic people with psychotropic medicines.