Fryers House - Care Home with Nursing Physical Disabilities

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• 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 remained 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 previously in breach of legal regulations relating to safe care and treatment, safeguarding and staff recruitment.

At this assessment, we found the provider had not made sufficient improvements in relation to recruitment and remained in breach of the legal regulation relating to employing fit and proper staff. Safer recruitment processes were not consistently robust, which meant the provider could not always be assured staff were suitable to work with people.

The provider had made some improvements in relation to safe care and treatment; however, these improvements did not extend to medicines management. Ongoing shortfalls in the safe management of medicines meant risks were not fully mitigated. As a result, the provider remained in breach of the legal regulation relating to safe care and treatment.

The provider had previously been in breach of regulations relating to safeguarding and staffing. At this assessment, we found sufficient improvements in these areas, and the provider was no longer in breach of these regulations.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Since the last assessment, the provider had implemented effective processes for reviewing and learning from accidents, incidents and near misses. These included, conversational debriefs, competency assessments, spot checks and targeted training updates. Senior staff followed up incidents with people and relevant stakeholders as appropriate, ensuring people’s care plans were reviewed and updated in response. This ensured learning was identified, shared and used to improve practice and reduce the risk of recurrence.

Staff told us they felt there was a strong culture of learning, where they were included and listened to, and where their views helped shape improvements. Leaders told us they had established an open-door culture, where staff were supported to discuss and explore emerging themes, with learning routinely shared across the team. The manager described how theme-based, ad-hoc discussions were held as opportunities arose, enabling staff to openly reflect and suggest changes. This approach helped make learning timely, relevant and embedded into every-day practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The provider supported people to transition into the service, including following hospital discharge, and kept in contact with health professionals to support people safely back to their home.

At the last assessment, we found contact with external professionals was sometimes delayed. At this assessment, we found this had improved. People confirmed they were supported to schedule and attend appointments as needed and supported to contact healthcare services and professionals. Relatives also confirmed people were supported to attend appointments where required.

People were assisted to arrange transport and were accompanied to routine health appointments and health checks. This helped maintain continuity and reduce risks during transitions. Staff shared examples of how they supported people to attend appointments and described the steps they would take to ensure people’s needs were met during transitions.

When people needed to go to hospital, the provider had clear systems in place to support them. This included the use of hospital passports, to give hospital staff important information about people and their health when they go to hospital.People told us they were involved in meetings with health and social care professionals, which promoted coordinated care and safe transitions.

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.

At the last assessment we found safeguarding systems and practices were not consistently effective, at this assessment we found this had improved.

People told us they felt safe and were confident staff would act to protect them from harm. One person told us of their experience where staff had raised a safeguarding concern promptly and they were spoken to about the action being taken and kept informed throughout. They told us they were satisfied with how the concern had been responded to and dealt with.

Staff demonstrated a good understanding of safeguarding and their individual responsibilities to recognise, respond to and escalate concerns. Safeguarding concerns were shared promptly and appropriately with relevant professionals, supporting timely intervention and risk reduction.

At the last inspection, we were concerned that restrictive practices were not always supported by appropriate mental capacity assessments or best interest decisions. At this assessment, records showed these safeguards were in place where required.

Staff demonstrated an improved understanding of mental capacity, consent and best‑interest decision‑making, recognising this as a key safeguarding responsibility. Records showed capacity assessments and best‑interest decisions were completed where required, with appropriate involvement of people and relevant professionals. This reduced the risk of restrictive or improper practice and ensured people were protected from unlawful treatment and avoidable harm.

The provider worked with people to identify and manage risks, and staff generally provided safe and supportive care. However, the provider did not apply this approach consistently for everyone, which meant staff did not always manage risks in a way that fully supported people’s safety, involvement and ability to do what mattered to them.

At the last assessment, we found the provider did not work consistently with people to understand and manage risks. At this assessment, we found some improvement. Care plans and risk assessments had been reviewed and updated, and staff were able to describe how risks were managed in practice. People confirmed risks were generally discussed with them, helping them feel informed and supported.

Staff identified most risks clearly and recorded appropriate actions to reduce the risk of harm. For example, they effectively detailed and managed risks relating to skin integrity, moving and handling, and urinary tract infections. However, the provider did not apply its risk management processes consistently across all people’s risk assessments. For example, one person’s epilepsy care plan did not clearly explain when staff should escalate concerns to emergency services, although another person’s epilepsy care plan contained this information.

This meant people were not always consistently supported to understand and manage risks in ways that fully upheld their rights and safety. While systems had continued to improve since the last assessment, further work was needed to ensure risk management processes and people’s involvement were embedded and applied reliably for everyone.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

At the last assessment, we found environmental safety and fire risk management were not consistently effective. At this assessment, we found this had improved.

The provider maintained the premises in a safe condition. Fire doors and external gates were closed and secured, and we found no concerns relating to environmental security during our site visits. This reduced the risk of unauthorised access and supported people’s safety within the service, which had been a concern at the last assessment.

Since the last assessment, the provider strengthened its fire safety arrangements. Staff completed fire drills regularly and consistently described the actions they would take in the event of a fire or other emergency. This demonstrated improved confidence and showed fire safety systems were embedded into everyday practice.

The provider monitored and maintained equipment in line with a planned schedule, with records showing regular checks and servicing. People told us the environment felt safe and well maintained and said the provider’s responsiveness had improved since the last assessment. Several people shared examples of how the new manager acted promptly to resolve an ongoing issue with overhead hoists. People told us this showed the manager listened to their concerns, responded appropriately and took action to address issues raised.

The premises remained spacious and accessible, and people continued to personalise their bedrooms as they wished. At the time of the assessment, renovation work was taking place. People told us they had been actively involved in discussions and plans about the renovations, which helped them feel consulted and considered during changes to the environment.

The provider did not always make sure staff were safely recruited and appropriately vetted for their roles. Although the provider generally supported staff through training, induction and supervision, and staff worked together to meet people’s needs, recruitment processes were not consistently robust.

At the last assessment, the provider did not ensure staff were consistently supported, competent or safely recruited. At this assessment, we found improvement in how the provider trained and supported staff; however, shortfalls in safer recruitment processes remained.

The provider did not consistently follow safer recruitment procedures, and this remained an area of concern. Recruitment records did not always demonstrate that the provider had completed appropriate pre‑employment checks in line with legal requirements designed to ensure staff are suitable to work with children or vulnerable adults. For example, some staff files did not include a full employment history or sufficient assurance about conduct in previous care roles involving children or vulnerable adults.

Since the last assessment, the provider had strengthened training, induction and staff support arrangements. People using the service told us they felt staff were trained and able to meet their needs effectively.

Staff completed training relevant to their roles, including training tailored to people’s specific support needs. The manager had also introduced additional group discussions to reinforce learning and support staff. For example, we saw evidence of discussions that supported staff understanding of safeguarding and how to apply Mental Capacity Act principles in practice.

Staff told us they felt supported through induction and supervision and described leaders as accessible and approachable. Staff said they raised concerns and sought guidance when needed, which helped them develop confidence and competence in their roles.

The provider maintained oversight of agency staffing. Agency profiles contained up‑to‑date information and detailed the training agency staff had completed, which helped reduce risks associated with staff unfamiliar with people or the service. While agency staff were supported through oversight arrangements, feedback from people indicated they did not always experience the same level of consistency when supported by staff who were less familiar with their needs.

Some people and relatives told us they were concerned about ongoing staff turnover, including changes in service leadership, and said this sometimes affected the consistency of care. People said this was more noticeable when they were supported by staff who were less familiar with them. People and staff also told us the interim manager had a positive impact on the service, providing greater visibility and support during a period of change. Leaders described their commitment to recruiting a permanent manager and strengthening staffing stability, alongside continuing to support staff through training, induction and supervision.

Although improvements in training, induction and staff support reduced risks in day‑to‑day care delivery, the recurrence of recruitment concerns showed the provider had not sufficiently strengthened or embedded safer recruitment systems. As a result, the provider could not always assure themselves that staff were fully vetted before starting work, which increased the risk of unsuitable people being employed.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not always involved in planning.

At the last assessment, significant shortfalls in medicines management placed people at risk. At this assessment, we found similar concerns, showing learning from previous findings had not resulted in sustained improvement.

Since the last assessment, the provider had introduced an electronic medicines administration record (eMAR) system. However, reviews of eMAR records showed ongoing inconsistencies. While allergy information was recorded, records did not consistently include key guidance such as how people preferred to take their medicines or clear instructions for when‑required and variable‑dose medicines. This meant the provider could not always be assured medicines were administered safely, appropriately or when needed.

Staff also did not consistently record the dose administered for variable‑dose medicines, including insulin and bowel medicines. In one case, a person with capacity sometimes chose to receive a different dose to that recommended based on their readings. However, staff did not consistently record the rationale for this decision or evidence that the person understood and agreed to the deviation. This meant medicines records did not clearly demonstrate how decisions were made, placing people at risk and leaving staff without sufficient protection.

The manager told us they believed medicines shortfalls identified at the previous assessment had largely been addressed by the previous manager and had therefore prioritised other areas for improvement. However, assessment findings showed not all actions had been completed or embedded, particularly following the introduction of the electronic eMAR system. Misunderstanding among staff about which paper records should remain in use during the transition contributed to inconsistent recording.

While the provider took prompt responsive action in response to concerns identified during the assessment, medicines governance systems had not prevented the recurrence of known risks, and audits had not identified the issues found. As a result, people remained exposed to an ongoing risk of harm, and the provider had not demonstrated sufficient improvement in medicines optimisation since the last assessment.

Leaders acknowledged the reasons for the lack of progress, engaged openly with assessment findings, and took timely action to address identified shortfalls, giving assurance that improvements were being actively progressed.

The service stored medicines securely, including any specialist drugs, and maintained medicines within recommended temperature ranges.