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The Firs Residential Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 25 March 2021

About the service

The Firs Residential Care Home provides accommodation and personal care for up to 12 people, including people living with dementia, in one adapted building. At the time of the inspection 11 people were living at the service.

The service is also a domiciliary care service. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of the inspection five people were receiving personal care as part of their care package.

People’s experience of using this service and what we found

Systems and processes were in place to regularly assess and monitor the health and safety of the environment, premises and equipment, including fire safety and risks associated with legionella. However, governance procedures had not identified the shortfalls in the fundamental standards found during this inspection.

Improvements with medicines were required. This was particularly in relation to the storage of medicines and the guidance for staff of how to administer prescribed medicines.

Incidents and accidents required further review and analysis, to ensure known risks were sufficiently assessed, monitored and mitigated and lessons learnt.

Guidance provided for staff about people’s care needs and routines were overall individually personalised. However, information relating to people’s health conditions lacked detail in places. At the time of the inspection, care plans and risk assessments were being reviewed to ensure they were sufficiently detailed and up to date.

Staff were aware of their role and responsibilities to safeguard people from abuse and avoidable harm. Additional and refresher training had been planned to ensure all staff were knowledgeable and competent in meeting people’s individual care needs.

People who used the service and feedback from relatives were in the main positive. This included comments about the staff and management teams caring and responsive approach.

People receiving care in their own homes were introduced to new staff before they provided care. In the main care calls were provided on time and staff stayed for the duration of the call. At the time of the inspection, checks by the management team to assure themselves staff were meeting people’s individual needs such as spot checks were not happening. However, the management team had regular contact with people and or their relatives and addressed any concerns raised immediately.

The provider completed recruitment checks when staff commenced their role to ensure as far as possible staff were safe to care for people. A dependency tool was used to determine what staffing levels were required to meet people’s individual needs and safety in both the service and people in their own homes the community.

Since the last inspection, the registered manager had left the service and the new manager was in the process of registering with CQC. Staff reflected on the change of management and overall were positive about the new managers support and leadership.

The provider had submitted statutory notifications to notify CQC of events they are required to report. Staff worked well with external health care professionals to meet people’s individual care needs.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 24 April 2018).

Why we inspected

The inspection was prompted in part by notification of a specific incident. The information CQC received about the incident indicated concerns about the management of risks associated with choking. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only. This inspection examined those risks. We found no evidence during this inspection that people were at risk of harm from this concern.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has deteriorated to Requires Improvement.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Firs Residential Care Home on our website at


We have identified one breach in relation to governance of the service. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 25 March 2021

The service was not always safe.

Details are in our well-led findings below.



Updated 25 March 2021



Updated 25 March 2021



Updated 25 March 2021


Requires improvement

Updated 25 March 2021

The service was well-led.

Details are in our well-led findings below.