Fryers House - Care Home with Nursing Physical Disabilities

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

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 service was in breach of legal regulations in relation to people’s safe care and treatment, including how medicines were managed, staffing and recruitment.

This service scored 41 (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 consistently demonstrate a proactive culture of safety. Systems to support safe practice were not reliably applied, and safety concerns were not always effectively addressed. Investigations into incidents and complaints were not always robust, and some records lacked sufficient detail to support meaningful learning or improvement. Some investigations lacked clarity, with outcomes failing to identify or explain lessons learned. For example, one investigation noted mitigating factors such as lack of suitable personal protective equipment, yet no clear actions or learning were recorded.

Although staff described actions they would take following incidents, records lacked sufficient detail. This limited the provider’s ability to identify patterns, assess decision-making, or determine whether safeguarding thresholds had been met. In one case, an incident involving harm was misclassified as a near miss. Medicines-related incidents were not consistently reported, and repeated events suggested learning was not embedded to prevent recurrence.

Where lessons were recorded, they were not always clearly explained and evidence of follow-up was limited. For example, when unsafe nursing cover was identified, there was no documented explanation or plan to mitigate future risks. People and relatives said they were not always kept informed about investigations or outcomes, with some having to chase for updates. In some records, individuals were assured of feedback, but there was no detail of when or how this occurred. Comments from relatives included, “Communication is okay to contact them, but it is not so easy receiving information” and “I never received an update on the outcome.”

Changes in management exacerbated these issues, contributing to inconsistencies in oversight, documentation, and follow-through. Prior to the assessment, the provider’s governance processes had identified shortfalls in incident recording, understanding of notifiable incidents, and lack of regular reviews. While actions had been initiated, improvements were not consistently evident at the time of the assessment.

The provider worked well with its internal team of professionals but did not consistently collaborate with people and external healthcare partners to maintain safe, joined-up systems of care. We found that safety and continuity were not always assured across the care journey.

People told us, and we saw in records, that contact with external professionals was sometimes delayed, particularly in relation to chiropody. These gaps in responsiveness increased the risk of delayed care and reduced confidence safety was being proactively managed. Feedback from people, supported by our observations, also highlighted delays in accessing personal grooming services, such as hair care. People told us this had become an increasing need in the months leading up to our assessment. This suggested a decline in responsiveness and continuity. These delays may affect people’s sense of dignity and wellbeing, and could indicate a lack of continuity in how individual preferences and longer-term needs were recognised and supported.

Some relatives told us they were not always confident that information from appointments was properly shared or followed up. As a result, some felt they had to be directly involved to help ensure the right outcomes. This meant there was an increased risk that care and support may not remain person-centred during transitions.

The provider was responsive to feedback and took action to make improvements. This included making handovers between staff more effective and taking steps to strengthen their partnership with the GP surgery.

The provider did not work effectively with people and healthcare partners to understand what being safe meant to people or how to achieve it. 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. Concerns were not always shared promptly or appropriately.

Safeguarding systems and processes were not reliably effective. Care and treatment were not consistently planned or delivered in a way that met all aspects of people’s needs. For example, a safeguarding concern relating to oral hygiene had not been identified by the provider and reflected a failure to embed past learning into sustained practice.

Changes in management and staffing had contributed to a loss of confidence among people and their relatives. Relatives told us actions taken in response to safeguarding incidents had not always been sustained, citing ineffective handovers, delays in resolving concerns, and inconsistent communication.

We were not assured the provider consistently applied the principles of the Mental Capacity Act 2005, including the Deprivation of Liberty Safeguards. For example, restrictive practices were imposed without a recorded mental capacity assessment or best interest decision, and the supervisory body not informed. Although the provider had recognised mental capacity and best interest recording as areas for improvement, they had not identified the specific risks posed by restrictive practices lacking appropriate legal safeguards prior to our assessment. We were not assured about the provider’s ability to consistently uphold people’s rights, ensure lawful and proportionate care, and protect people from the risk of improper treatment.

Overall, safeguarding practices did not consistently uphold people’s rights or protect them from harm. However, the provider demonstrated a commitment to improvement and had begun taking steps to address the concerns raised.

The provider did not 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.

The provider had an inconsistent approach to risk management and did not always ensure care plans and risk assessments were updated when people’s needs changed. Risks were not always clearly assessed, leaving staff without guidance to provide safe, consistent care or support people in managing risks. For example, epilepsy related risks. Actions to mitigate risks, such as seizures during water-based activities, were not recorded. This increased the risk of harm for people.

Systems and processes were not always effective in ensuring people’s rights were upheld or that they were protected from avoidable harm. For example, risks linked to restrictive practices, such as social isolation, were not always considered or addressed in a person-centred way. This increased the risk people were not involved in understanding or managing risks in ways that supported choices, upheld rights and helped them do what mattered to them.

Although care plans and risk assessments were reviewed regularly, these reviews often lacked meaningful detail. For example, we found updates recorded as ‘no changes’ without evidence of people’s involvement or reflection on whether needs, preferences, or risks had changed. This limited opportunities to identify and respond to changing needs and ensure care remained appropriate.

Care planning records did not consistently reflect current support needs. Some contained outdated or contradictory information. This increased the risk of unsafe or inconsistent care and limited people’s ability to be active partners in managing risks. While 2 people told us they felt involved in their care planning, they also expressed concern that this was not the experience of others living at the service. One relative commented, “No recent review of the care plan has been made,” while another reported that there had been no review of the person’s care for at least 18 months.

The provider had begun to identify these shortfalls and was responsive to feedback. They began reviewing care records and took steps to develop staff, improve reviews and support collaborative care planning.

The provider did not always detect and control potential risks in the care environment. One relative told us, “Staff turnover causes problems for residents because it is not a safe environment for them, no stability, highlighting how inconsistent staffing contributed to a sense of insecurity and instability within the care setting.”

Facilities and security arrangements were not consistently maintained to support the delivery of safe care. We identified concerns relating to environmental safety, such as, fire doors not being consistently closed when not in use and external gates not always locked and secured. These shortfalls posed risks to both the physical safety of people using the service and the overall security of the environment. Although the provider took action in response to our feedback, we observed repeated instances across multiple days. This indicated the arrangements in place for monitoring and maintaining the safety of the premises at the time of the assessment were not always effective. The changes implemented required time and reinforcement to become embedded in routine practice.

We identified shortfalls in fire risk management in relation to fire drills and associated records. They lacked sufficient detail, including key information such as who had participated, the duration of the evacuation, and the scenario tested. These omissions limited the provider’s ability to evaluate the effectiveness of fire drills and ensure staff and people using the service are adequately prepared in the event of a fire. Feedback from staff regarding their awareness and confidence in responding to a fire was varied. While some staff demonstrated a clear understanding of procedures, others expressed uncertainty about what actions they would take in the event of a fire. This highlighted the need for more robust fire drill procedures and clearer communication to ensure all staff were confident and competent in emergency situations.

People were positive about the premises and confirmed they were able to decorate their personal bedrooms as they wished. The home was spacious and fully accessible for wheelchair users. Equipment was monitored and maintained according to a schedule with regular servicing.

The provider did not ensure staff were consistently equipped, skilled, and supported to carry out their roles safely and effectively. They did not always make sure staff received effective support, supervision and development. There was insufficient evidence of robust induction processes, competency assessments, regular supervision, and role-specific training. This increased the risk that staff lacked the confidence and capability to deliver safe, person-centred care. Feedback from staff indicated that not all felt adequately inducted into their specific roles. One staff member told us, “It’s not working well at the moment, too many new staff; they need inducting and support.”

The provider had failed to complete all required pre-employment checks for some staff, undermining assurance that individuals were suitable and appropriately vetted for their roles.

These shortfalls exposed people to an increased risk of harm and compromised their safety, dignity, and wellbeing, particularly those with complex support needs. People told us, and we observed, that day-to-day staffing levels were generally sufficient. However, they also noted a decline in the quality of support when care was provided by staff who were less familiar with them and the home. One person told us, “When new staff, they don’t know what they are doing.”

Comments from relatives included, “The staff turnover is an issue because (person’s name) is not then with the same staff that she can become comfortable with, and this is causing irritation and frustration to her”, “The staff changeover is the worst I have seen for a long time, and this impacts the service users more than anyone else” and “The agency staff are not trained staff for the people that use the service at Fryers House.”

Prior to the assessment, the provider had increased staffing levels, in part to enable staff new to the home time to become familiar with people and the environment. They had also identified training gaps through internal governance processes and had begun to address these. Measures included changing training provider and increasing access to training courses, implementing targeted re-training and staff support, implementing a supervision schedule and strengthening internal oversight.

The provider assessed and managed the risk of infection. People were supported to live in a clean and well-maintained environment, with processes in place to support staff to manage infection risks and follow safe food hygiene practices. Regular checks were carried out to confirm cleaning tasks were completed, and food safety measures, such as fridge temperatures recordings, were maintained. People confirmed the home was regularly cleaned and that staff used personal protective equipment (PPE) appropriately. Staff told us they had access to sufficient supplies of PPE and cleaning products.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We could not be assured that people received their medicines in line with prescribers, or manufacturer instructions. For example, when medicines were crushed to aid swallowing or administered via a feeding tube, staff had not sought advice from a pharmacist to ensure the crushed medicines would be effective. Additionally, where medicines were required to be given before food or separately from other medicines, records showed they were administered with other medicines. This could make the medicines less effective.

Staff told us that they did not have dedicated time to check, order, and book in medicines. Audits highlighted instances where some medicines ran out mid-month, while others were overstocked or unaccounted for. This could mean that medicines were not available when people needed them. Medical gases were not stored safely and with the appropriate signage.

Systems and processes to manage medicines safely were not effective. Information was in place for staff to support people with their emotions, but was not consistently used. Therefore, we were not assured that people were supported appropriately and that medicines prescribed were used appropriately to manage these emotions. Allergy information was also not consistently recorded.

Training records showed that all nurses administering medicines had undertaken training. However, the policy did not indicate the frequency it should be refreshed, nor did records indicate if staff had a recent competency assessment. It was therefore unclear if they were up to date and competent to administer medicines. Audits had not identified the issues found during the assessment.

These medicines management shortfalls reflected broader issues in workforce development and oversight, impacting safe care and governance, as detailed elsewhere in this report.