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Fewcott House Nursing Home Outstanding

All reports

Inspection report

Date of Inspection: 14 August 2013
Date of Publication: 18 September 2013
Inspection Report published 18 September 2013 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 14 August 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members, talked with staff and reviewed information given to us by the provider. We reviewed information sent to us by commissioners of services and talked with other authorities.

Our judgement

The provider did not have an effective system to regularly assess and monitor the quality of service that people received. The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

Reasons for our judgement

The provider did not have an effective system to fully assess and monitor the quality of the service that people received. The provider told us they had not requested any formal reporting from the manager of the home or clinical lead to inform their assessment of the quality of the service. The provider said “I’m here seven days a week. I can see. I speak to residents and family”. We asked if there was an audit plan and we were told that the provider did not have oversight of the audit system that was in place.

There was a risk of people receiving poor care because of a lack of quality monitoring. For example, we could not find evidence that the food and fluid charts were being audited to ensure that people were drinking enough. We looked at do not attempt resuscitation (DNAR) forms held on people’s files. We were told that a system of reviewing DNAR forms had not been in place previously. We saw that a number had not been correctly completed and often lacked information on the involvement of the person. There was a risk that treatment may not have been in line with the wishes of people or delivered in their best interests. We were told that the provider was currently undertaking a review of all DNAR forms held in people’s files.

We found that the service lacked systems to ensure that decisions in relation to the provision of care were made appropriately. For example, we looked at the use of bed rails. This equipment can be used as a form of restraint and therefore comprehensive records about their use should be kept in accordance with the mental capacity act (MCA) good practice guidance. We could not find appropriate records in care files and also found that some staff lacked training in the MCA. We also found that monthly routine inspections of bed rails were not regularly recorded in line with Fewcott house policy. We were told that an audit of care plans had not been undertaken. Therefore the provider could not be assured that care plans and risk assessments were up to date and fit for purpose. We were told that a new care plan system was being introduced and that each person’s care plan would be reviewed and updated in the autumn.

There was no evidence that learning from incidents took place and appropriate changes had been implemented. For example, we looked at the accident and incident records. We found there had been lots of recorded falls. We asked if an audit of falls had been undertaken and what falls planning was in place. The provider told us that the clinical lead had undertaken a falls audit, but was not able to locate the audit or inform us of any action that had been taken as a result.

The provider did not have an appropriate system in place for monitoring the performance of staff in the home. We were told that the provider had been made aware of poor practice amongst staff by an external agency. This practice had not been identified by the internal monitoring system. The poor practice was being addressed by the provider at the time of our visit. We saw records of responses to complaints from the home manager. Responses acknowledged people’s complaints and where appropriate provided an apology. However, it was not clear from the information supplied whether complaints had been taken account of to improve the service.