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Archived: Friary Fields Care Home Inadequate

We are carrying out a review of quality at Friary Fields Care Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 16 January 2020

About the service

Friary Fields Care Home is a care home that provides personal care and nursing for up to 34 people in one adapted building. At the time of the inspection 21 people lived at the home.

People’s experience of using this service and what we found

People were not safe at Friary Fields. The environment was not safe. People were placed at risk of serious harm due to elevated fire risk and inadequate fire risk management. There was an increased risk of legionella developing in water supply and people were exposed to the risk of sustaining burns due to a failure to manage risks associated with hot water and exposed hot surfaces.

Risks associated with people’s care and support were not managed safely. Measures were not in place to reduce risks associated with falls, health conditions, moving and handling and pressure ulcers. Equipment was not always used safely or effectively. For example, some people were unable to call for help as call bells were not within their reach. These issues placed people at risk of harm.

People were provided with care which was degrading and disregarded their need for care and support. Staff were not deployed effectively to meet people’s needs and ensure their safety. Furthermore, staff worked long shifts, back to back which could have led to exhaustion and compromised people’s safety. Medicines were not managed safely, and some people did not receive their medicines as prescribed. The home was not clean and good food hygiene practices were not followed. This could have had a negative impact upon people’s health.

The home was not well led. The provider did not have the skills, competency or resources to run Friary Fields Care Home. People’s health and safety was at risk due a failure to identify and address issues and poor practices. Although we found that the service worked with partner agencies, feedback from professionals was poor. Information had not always been shared in an open and honest way with people, their families or staff.

Following our inspection the local authority made arrangements for people to be moved to new homes.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was requires improvement (published 11 September 2019) and there were multiple breaches of regulation. Following this inspection we served two warning notices on the provider in relation to safe care and treatment and governance.

Why we inspected

The inspection was prompted due to concerns received about safety, quality and leadership. A decision was made for us to inspect and examine those risks.


We have identified three breaches of the legal regulations. These were in relation to safeguarding, safe care and treatment and governance. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

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Inspection areas



Updated 16 January 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 11 September 2019

The service was not always Effective

Details are in our Effective findings below


Requires improvement

Updated 11 September 2019

The service was not always Caring

Details are in our Caring findings below


Requires improvement

Updated 11 September 2019

The service was not always Responsive

Details are in our Responsive findings below



Updated 16 January 2020

The service was not well-led.

Details are in our well-Led findings below.