The Firs Residential Care Home

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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, person-centred care and staffing.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. We saw evidence of people experiencing unwitnessed falls and while staff completed incident forms there had been no review of incidents by the registered manager to explore possible reasons and mitigate the risk of further falls. Staff did not have access to a falls protocol to help them support people after a fall. This meant the service had repeatedly missed opportunities to share lessons learned and make improvements which placed people at the risk of ongoing harm from falls.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. Management did not have comprehensive oversight of the service and the level of care people were receiving. While staff supported and worked well with visiting professionals such as district nurses, they did not have access to people’s latest health information or updated care plans. A professional who worked with the service said, “It’s hard, the registered manager has not been here on my last 3 visits and staff can only tell me so much, there is little response to our communication [emails] which makes it hard to support care and improvements.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not share concerns quickly and appropriately. Staff we spoke with were able to identify what concerns or incidents might have been needed to be reported as a safeguarding. However, staff were unclear on how to report their concerns. One staff member said, “The registered manager deals with reporting safeguardings but when they are not here we don’t know what to do, we don’t have access to the system to do it. I recently had a concern and reported it to [a visiting professional] so they could report it for me.” We asked to see the provider’s safeguarding records but were not provided with this information.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care plans and records did not reflect people’s needs or wishes. There was no evidence within care plans that people and/or their relatives had been involved in the assessment or review of their care. For example, 2 people required 1-1 support during mealtimes due to periods of anxiety and frustration which had led to physical aggression. There was no evidence that staffing levels were appropriate to support this. Records such as incident forms or behaviour charts had not been completed to show these periods of anxiety meaning people were at risk of receiving inappropriate care or not having their medical and health needs escalated and referred to other professionals.

The provider did not always detect and control potential risks in the care environment. The provider and registered manager were aware of concerns about the environment from third party professionals which included fire safety risks and a structurally unsafe retaining wall to the side of the property. Despite this awareness minimal action had been taken to mitigate the risk and ensure people’s safety. The area outside near the unsafe wall had been taped off, however people including those living with dementia had unsupervised access via unlocked and unalarmed doors leading to the rear of the property. The fire authority had given advice about blocked fire exits needing to be cleared. On the assessment we found an exit was still inaccessible due to the storage of moving and handling equipment. Furthermore, 2 people who resided on the 1st floor had mobility issues and needed equipment to support them to mobilise. There was no carry down equipment available, such as an evacuation mat, in the event of an emergency. This meant that in the event of a fire staff would not have been able to support people safely or in a timely way to evacuate the building which placed them at significant risk of harm.

The provider did not make sure there were enough qualified, skilled and experienced staff to support people with their care and support. The registered manager was responsible for delivering practical training in first aid and moving and handling. Staff had not received training in basic first aid and life support as the registered manager’s own qualification to provide this had expired and they had not sought any additional training from an external provider. Some staff had not received practical moving and handling training for equipment such as a rotunda or hoist. The registered manager stated this equipment was not in use, so they felt it inappropriate to train staff. However, care plans clearly evidenced people required support with their daily care needs and in the event of an emergency to move with the support of a hoist or rotunda. One staff member said, “I am the only person on shift today trained to use a hoist so that means I cannot support those people properly or safely as a hoist needs 2 staff members.” Staff rotas and training records we reviewed supported what this staff member had told us. This meant people were placed at the risk of harm from not receiving their care or at risk of injury from being moved by inexperienced and untrained staff.

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.

While the home was clean and maintained to a high standard of cleanliness, we observed repeated failures with the appropriate use of personal proactive equipment (PPE) such as aprons and gloves. For example, staff did not wear gloves or an apron when entering the kitchen during the mealtime service. Staff supported people with meals where needed but did not wear any PPE. We observed staff stroking people’s hair and cleaning tables and then proceed to handle food without any PPE. This placed people at risk of harm from cross contamination and spread of infections.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. Systems were not in place to safely administer and store medicines. People did not always receive their medicines as prescribed. We reviewed records for three people and saw that they had received above the maximum recommended dose of their pain relief. This meant that they were at risk of serious harm from overdose. When medicines were not given staff did not always document the reasons why. We reviewed the records for one person who staff told us were at the end of their life. There were no medicines available at the service to support their end-of-life care, and staff were unsure whether a medical assessment had taken place.

Topical creams were not always applied as prescribed and there was no guidance available for staff indicating where these creams should be applied.

Care plans lacked information for staff to support people with complex conditions. For example, we reviewed care plans for two people who had diabetes. There was no guidance on recognising or treating hypoglycaemia (low blood sugars). Staff did not know where emergency rescue packs were located for hypoglycaemia.

Medicines were not stored safely. We found that the refrigerator used to store medicines, including insulin and antibiotics, had been switched off for five days without staff noticing. This posed a serious risk to people's health, as medicines may have become ineffective.

We reviewed a sample of medicines error forms submitted by staff and found that they had not been appropriately investigated by the manager. Staff told us that learning from errors was not shared