Fountain Nursing and Care Home Limited

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of 3 legal regulations in relation to safe care and treatment due to inadequate care planning and risk assessment; environmental risks; and staffing.

This service scored 25 (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.

The culture within the service was not focused on safety and learning. Many known risks to people were not assessed and further information for staff was needed about how the risks would be managed. There was no system in place for consistent analysis of incidents, including displays of distress which people expressed. This meant there were missed opportunities to drive improvements in the service from lessons learnt in relation to incidents which occurred. For example, there was no investigation or detailed analysis as to what led 1 person to become frequently distressed, or how effectively they had been supported by staff. This meant there was a lack of understanding of how to reduce the risk of reoccurrence. Although there was a record of complaints or compliments which were received, there was no analysis of these to support future learning and improvements. There was also a lack of robust evidence to demonstrate outcomes of any learning was discussed with staff. A lack of clear and consistent guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not always demonstrated. This meant opportunities for learning and improvements in people’s care were sometimes lost or delayed.

People and relatives told us they could contact the service if they had any concerns about their care. Most told us they had met or spoken with the registered manager and knew they were able to speak with them if they needed to. A relative told us, “The manager is very approachable, I can always knock on her door. My only complaint was about [name]. The person’s nails were dirty, and it was sorted."

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.

Although systems were in place to ensure people’s needs were assessed prior to moving in, these were not robust. Records held by the provider failed to demonstrate there was adequate information for robust continuity of care, including when people moved between different services. This included when people transferred to hospital due to their health conditions having deteriorated. Most staff we spoke with knew people and their support needs well. The provider had failed to monitor and audit the records of the care and support provided by staff, ensuring records and subsequent actions were clearly documented.

Most relatives told us, overall, they felt informed and involved when their loved one was moving into the service and were kept up to date with changes verbally.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

We found the provider failed to consistently recognise what safeguarding meant and had not recognised or responded appropriately to potential abuse. They failed to carry out robust investigations into these incidents and make appropriate safeguarding referrals to protect people from abuse. At this assessment, we found a widespread failure to recognise potential abuse and protect people from potential harm and report such concerns. For example, for 1 person who was known to be at high risk from falls who had fallen and sustained a head injury, the provider failed to seek timely medical advice and report this unwitnessed fall resulting in injury. For another person who had no protective bumpers on their bed rails, as they removed them, the provider had failed to implement alternative risk management and report this to the safeguarding team. We also found this incident could have led to significant harm or even death, because guidance for staff to follow was not in place. We found this lack of guidance on management of known risks and health conditions was the case for all 10 people whose support plans we reviewed, and we raised safeguarding concerns due to the lack of systems to keep people safe. The service failed to consistently share concerns appropriately with relevant agencies, teams and professionals and this was confirmed by the local safeguarding team.

Staff had received safeguarding training and told us if they had any concerns in relation to suspected or actual abuse they would speak to the nurse or registered manager. Not all staff knew how to escalate concerns with other organisations. People told us they felt safe with the staff supporting them.

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.

At this assessment, we identified staff were not always provided with clear information and guidance on supporting people in relation to their known health conditions and managing associated risks. Risk assessments lacked clear guidance for staff to follow about how the risk should be managed. This included a lack of clarity on how to manage risks relating to people’s specific health conditions. For all 10 people who we reviewed, some known risks had not been assessed, so there was no guidance for staff about how these risks should be managed, which had the potential to put people at increased risk of harm. There was no information to support a person who may become distressed, which increased the risks to both the person and staff members. We saw staff members supporting people with complex needs had not had the opportunity to receive the relevant, in-depth training in people’s health conditions. Basic on-line training had been provided on health conditions, without any follow up by the provider to assess staff’s understanding and learning. This meant they could not be assured staff had the appropriate skills and knowledge to support people safely.

Some relatives told us they were contacted by staff and management following incidents occurring or new risks emerging involving their loved ones. Most told us they received information about changes to people’s support needs, but this was not consistent for all. Some relatives of people who lacked capacity to make their own decisions told us they had been involved with applications for Deprivation of Liberty Safeguards (DoLS) authorisations and meetings about decisions made in people’s best interests. Others told us they felt their loved ones known risks were well managed. However, we saw that risk assessments did not always fully reflect people’s rights under the Mental Capacity Act 2005 (MCA) and best interest decision-making did not always take place to demonstrate decisions made on behalf of others were in their best interests. For example, for 1 person we found bed rails were used to prevent them from getting up and walking around and they were putting their legs through the rails. This restriction had not been assessed in line with the person’s rights under the MCA and placed them at risk of serious harm.

Despite our findings there was no evidence that people had been harmed. Staff knew people’s needs and told us they understood how to manage people’s care in a safe way. People were supported by consistent staff.

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 provider failed to carry out robust environmental audits and risk assessments of the home and provide clear guidance for staff to follow. The provider failed to identify and take steps to control potential risks within the home. This included a failure to identify and manage risks in relation to fire safety; falls from height; unrestricted access to hazardous items and areas due to unsecured doors on which keypads were absent; and burns from hot surfaces due to broken or missing radiator covers and exposed hot water pipes in both private rooms and communal areas. There were no risk assessments in place to ensure mitigation of these risks. Where repairs or replacement furniture was required, this was not always carried out in a timely way. For example, 1 fire door was identified as needing to be replaced by a staff member in January 2025. However, when we carried out our assessment this still had not been completed. Pest control had visited the service and made recommendations. We found these had not been actioned in a timely way.

Where safety audits had been carried out by staff members who had been delegated to complete these tasks, we found these did not identify the risks we found in the service. The registered manager and provider had failed to check that the audits carried out by staff were in fact reflective of the actual service.

Staff were able to tell us what actions they would take if they found faulty or damaged equipment. However, our findings demonstrated the reporting of such issues was not consistent. There was a maintenance book for staff to record any required repairs in; however, this did not include the issues we found during our assessment.

Based upon our findings and the urgent risks these posed to people living at the service we made referrals to the fire service and the environmental health services, who visited the home to assess the risks to people living at Fountain Nursing and Care Home.

People and relatives we spoke with did not raise any concerns in relation to the environment being unsafe.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider failed to ensure all staff received appropriate training to meet the needs of people and their known health conditions. This included mental and physical health conditions with a long-term impact on people’s care, such as strokes, complex dementia, specialised dietary needs, and suicidal thoughts. The staff we spoke with told us they felt they had received enough training to support people with their known health conditions. However, we observed staff who did not respond appropriately or seek further support when a person exhibited distress. Staff members told us they had received training and induction from the provider and had the opportunity to shadow other staff members prior to supporting people. However, based on our observations and conversations with staff, the training staff had completed had not been effective in enabling them to meet people’s needs safely. No assessments had been carried out to assess the effectiveness of staff learning in key areas. For example, competency checks of staff skills had not been completed to observe their practice in areas such as supporting people with complex dementia. The provider and registered manager had also failed to carry out spot checks to ensure staff supported people appropriately. This meant the provider could not be assured staff were safely and effectively applying their learning when supporting people.

Staff supervision had been completed and recorded; however, these meetings were not always used to help drive improvements in the service. The provider did not ensure all staff were competent, skilled and had up to date training to carry out their role and effectively support people.

We found 1 staff member was working, without a day off for several weeks and this included working long days. We also found that 3 other staff, which included nurses, were scheduled to work excessive hours without the correct length of time between shifts. For example, 1 nurse worked the late shift, the night shift then the late shift the same day of which the night shift ended. The provider failed to have an emergency plan in place for ensuring the service was suitably and safely staffed. This placed the staff member and people at risk of harm due to staff fatigue.

The provider's recruitment systems were not robust. Safe recruitment practices were not always followed. People were at risk of harm from receiving care and support from unsuitable staff. Police checks had not been carried out by the provider for 1 staff member prior to them working voluntarily in the lead up to them being employed. Other staff members had current police checks in place. For the staff member for whom the check had not been carried out by the provider, they had failed to carry out any risk assessment of how they were mitigating associated risks. We found references obtained had not always been verified as completed by the intended referee, and prospective staff’s personal identification had not always been checked. The provider had failed to evidence that they had explored any gaps in employment records and mitigate any associated risks. The provider failed to ensure they had obtained all the information required to ensure the suitability of all staff employed. We observed multiple contractors and staff from another service carrying out work in the home, unsupervised, without evidence of their suitability having been checked.

This meant people were placed at risk as the provider had not carried out consistent checks to ensure all staff and contractors on site were suitable.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found people and staff were at risk as the provider had failed to ensure the furnishings in the service were suitable and were able to be adequately cleaned. For example, we found multiple chairs in the communal lounges and personal bedrooms had worn and damaged covers revealing the foam interior. We also observed over bed tables had exposed wood where the protective tops had worn. This meant that these could harbour bacteria and could not be adequately cleaned. We observed linen trollies in corridors which either did not have any bags attached for staff to put dirty linen into or they were so full that dirty linen had fallen from the trolley onto the floor. We also saw 1 occasion where clean linen was placed next to the dirty linen trolley which had the potential of cross contamination. Carpets in some communal areas and bedrooms were visibly dirty and, in some cases, smelt of urine. Paint on skirting boards, handrails and doors was chipped exposing the bare wood. The grout around sinks and toilets in people’s rooms was also observed to be visibly dirty and cracked. All these issues in these areas meant that bacteria could be harboured, and robust and adequate cleaning could not be carried out to prevent and reduce the spread of infections.

The provider's infection prevention and control (IPC) audits failed to identify the concerns we found in the service.

Throughout the assessment we observed staff wearing masks when supporting people although there were no reports of infection in the service. Staff we spoke with told us they wore masks to protect people from the risk of infection. This was not in line with current guidance or the provider’s own policies and procedures. There was no reference in people’s support plans which demonstrated a need for staff to wear masks when supporting them. All staff were following safe practices and were adhering to the safe disposal of personal protective equipment (PPE). This included gloves and aprons. The provider failed to operate an effective system to ensure all staff were subject to spot checks to monitor the safe and correct use of PPE. Staff told us the PPE they needed to prevent and control the spread of infection was available to them. Most staff had completed IPC training.

People and relatives we spoke with did not raise any concerns in relation to the cleaning or hygiene within the home.

The provider failed to ensure staff had clear, up-to-date guidance in relation to IPC, when supporting people with catheter care. This meant we could not be assured people were protected from the risk of cross-contamination or the increased risk of infections.

The provider did not make sure the administration of medicines and treatments were safe and met people’s needs and preferences. People were not involved in the planning of the safe administration of medicines.

The provider had failed to ensure robust systems were in place ensuring people’s medicines were stored safely and in line with current legal requirements. Providers should ensure that rooms used to store medicines are not accessible from outside. We found there was a window in the medicines room which did not have obscured or frosted glass and had not been fitted with any window restrictor, bars or other alternative security measures to minimise the risk of unauthorised access. Some action was taken by the provider during the assessment to reduce this risk; however, prior to our assessment they had not identified this risk.

Although there were first aid boxes in the service, we found some items these contained were 5 years out of date. Although audits of first aid boxes were taking place, these had not been effective or thorough.

People’s support plans were not always clear in relation to the level of support they needed with medicines. This meant there was a potential for people not being supported with their medicines, as required.

The information for staff members to follow for 'as required' (PRN) medicines, to ensure a consistent approach, was not always clear as to how, when or why to use such medicines. Without clear protocols in place, this could lead to staff not knowing when to give these medicines, leading to the potential for too much or too little medication to be given. For example, for 1 person who was showing distress, we saw staff failed to escalate this to the nurse in charge to assess whether it was appropriate to administer ‘as required’ medicines to help relieve the person’s distress.

For people who were prescribed creams to treat skin conditions, we saw these medicines were included on the medication administration records (MARs) or body maps. They had instructions on when, where and how the creams should be applied. Where people were prescribed medicines to reduce the risk of blood clots, which increased the risk of excessive bleeding, risk assessments were in place.

Audits of the medicines were carried out by a staff member. However, the provider did not carry out any checks of these audits to ensure they were accurate and thorough.

People and relatives we spoke with had no concerns in relation to the support people had with their medicines.