The Fields 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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation relating to the safety of the premises and equipment.
 

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty.

The manager maintained a record of safety-related incidents; however, there was limited evidence to demonstrate that incidents were consistently subject to robust investigation or that effective action had been taken to reduce the risk of recurrence.

Most care plan reviews were overdue, which limited opportunities to identify trends, review risks, and embed learning following incidents. Whilst there was evidence that team meetings had taken place, the manager told us attendance was generally poor, particularly amongst care staff, with participation largely limited to senior care staff. This reduced opportunities to share information, promote reflective learning, and ensure staff remained informed of changes to people's care and support needs.
 

The provider did not have robust systems in place to make sure there was continuity of care, including when people moved between different services.

The manager told us formal documentation such as hospital passports were not used. Instead, paramedics and hospital staff were supplied with a bundle of key documentation including resuscitation status and medication records, should any residents be required to transfer to hospital. However, we found some care files did contain hospital passports, but the information contained within them was not always accurate. For example, one person’s hospital passport was written in 2023 and described their dementia as being early onset. However, through discussions with the manager and observations of the individual, it was clear that their dementia was now more advanced.

Inconsistencies in formal processes, along with out-of-date information, could be result in incorrect information being shared in emergency situations.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt they felt safe with the staff and care provided. One person told us, “I feel safe here and the staff look after me well”. A relative told us, “The staff are very good and provide the help and support [name] needs to keep her safe.”

Whilst there was limited evidence of safeguarding activity, management and staff understood local safeguarding arrangements and worked in partnership with other agencies when concerns were raised. Information on how to report safeguarding concerns was available to staff, people, their relatives and visitors to the service.

However, the provider had not ensured the requirements of the Mental Capacity Act 2005 (MCA) were consistently followed. The MCA provides a legal framework for making decisions on behalf of people who may lack the mental capacity to make specific decisions for themselves.

We discussed this with the manager, who told us consent relating to the administration of medicines had been considered. However, they acknowledged consent to care and treatment had not been formally sought, assessed, and recorded for all people living at the service.

For example, we reviewed the records of one person who lacked capacity and found there was no documented evidence of consent relating to their care and support. Another person who lacked capacity had a consent record in place; however, despite having a Relevant Person's Representative (RPR) appointed, there was no evidence that the RPR or family members had been consulted regarding decisions made on the person's behalf.

This meant the provider could not demonstrate that decisions were being made in accordance with the principles of the MCA, or that appropriate involvement of representatives and those interested in the person's welfare had taken place where required. As a result, people were at risk of receiving care and treatment that had not been appropriately authorised or documented.
 

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some people's care plans and risk assessments were detailed and person-centred, providing information about their preferences, how they wished to be supported, what was important to them, and the measures required to keep them safe. Staff had access to guidance that enabled them to support these people safely and in accordance with their individual wishes.

However, other care plans and risk assessments lacked sufficient detail and were not consistently tailored to people's individual needs and circumstances. This increased the risk that staff did not have the information required to provide safe, consistent, and person-centred care.

A care plan was in place for one person who preferred prescribed cream to be applied in a specific manner, as they could become distressed if these preferences were not followed. However, the care plan did not contain sufficient detail regarding the person's preferred method of application. This meant staff did not have clear guidance to support the person consistently and in line with their preferences. We raised this with the manager during the inspection, who acted promptly to update the care plan to include the necessary information.
 

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The manager maintained a detailed record of all checks undertaken on equipment used within the service. However, during an initial walk round of the building, two people’s rooms on an upper floor, an ironing room / hairdressers on an upper floor, a conservatory window on the ground floor and a lounge window on the lower ground floor were all observed to lack window restrictors.

This posed a significant risk to people, especially those living with dementia. This was discussed with the manager of the service who advised us that these windows had all been assessed but were deemed not to pose a risk. By day 2 of the inspection, window restrictors had been fitted to these windows except the ironing / hairdressing room as entry to this room was protected using a secure key code entry system.

A subsequent thorough review of window safety identified that all windows restrictors in place were of a chain design and were not robust. The majority opened further than 10cm and all were not tamper proof with screw fixings clearly visible. This was discussed with the manager of the service who was not aware of the guidelines around window restrictors as set out by the Health and Safety Executive (HSE). The manager has subsequently put plans in place to have all windows fitted with correct restrictors.

Furthermore, large furniture items such as wardrobes and cupboards were not secured to walls. This posed a risk to individuals living at the service.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,
supervision and development.

Review of staff training records showed staff had not received training in learning disability care. The Health and Care Act 2022 introduced the need for all CQC-registered service providers to make sure their staff have training on learning disability and autism, at a level appropriate to the role of the individual member of staff. We also identified that some people living at the service had a diagnosis of Parkinson's disease; however, there was no evidence that staff had received condition-specific training to support people with this need.

We discussed this with the manager, who told us they understood learning disability training was only required where staff were directly supporting people with a learning disability. This demonstrated a lack of awareness of the importance of ensuring staff have appropriate knowledge and skills to meet the diverse needs of people using the service.

The absence of relevant training increased the risk of staff not having the necessary understanding to provide care and support in line with people's assessed needs. Following our discussions, the manager took action to source appropriate training in both learning disability care and Parkinson's disease awareness.

The manager used a dependency tool to determine staffing levels. Staff told us they generally felt staffing levels were adequate, however they felt rushed during busy times such as mornings and at mealtimes. On occasions, we observed call bells sounding for a prolonged period. We observed that most staff were gathered on the lower ground floor. However, due to the layout of the building, this meant staff were not deployed effectively around the building, particularly at mealtimes when a number of people chose to eat in their room.

Recruitment practices were generally satisfactory. We identified one member of staff who only had one reference, however the manager assured us that a second reference had been obtained but filed incorrectly.
 

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.

People were protected from the risk of infection. The provider had systems and processes to assess and manage the risk of infection. Spot checks were completed, which included observations and discussions with staff to ensure they were following effective infection prevention practice. Staff explained they had access to personal protective equipment (PPE) and disposed of this safely.

The home was clean, free from clutter and malodour and we observed dedicated staff cleaning the building throughout the inspection.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Overall, medicines were managed safely, and Medication Administration Records (MARs) were completed accurately and maintained up to date. However, care plan reviews had not been completed consistently, resulting in some care plans containing outdated information relating to prescribed medicines, including dosage details.

We discussed this with the manager, who told us they considered the information to be acceptable provided the MAR chart reflected the current prescription. However, the presence of conflicting information across records increased the risk of staff relying on inaccurate guidance, which could compromise the safe management of medicines and place people at risk of harm.

The manager took immediate action to review and update the relevant care plans to ensure information was accurate, consistent, and reflective of people's current prescribed medicines.