1 March 2022
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
As part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.
This inspection took place on 15 February 2022 and was announced. We gave the service 24 hours’ notice of the inspection.
1 March 2022
We undertook an unannounced focused inspection of Friston House on 24 July 2018. The team inspected the service against two of the five questions we ask about services: is the service well led, is the service safe?
No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.
Friston House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Friston House provides accommodation, residential and nursing care for up to 81 older people. The home comprises of three units. The main building has two floors and accommodates people with residential needs with early onset dementia on the ground floor; and people with nursing needs on the first floor. There is a separate 'Memory Lane Unit' for people who live with dementia and nursing care needs.
On the day of our inspection there were 78 people living at the home. People had a variety of complex needs including people with mental health and physical health needs and people living with dementia. Some people had limited mobility, pressures ulcers and some people received care in bed.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager became registered on the day before we inspected the service. They had previously been in post as the peripatetic general manager.
At the last inspection on 03 and 06 October 2017 the service was rated Good overall and Requires improvement in Responsive. We had made a recommendation in the Responsive domain that registered person's reviewed activities following good practice guidance to ensure people have access to activities and hobbies to meet their needs.
There were enough staff deployed to meet people’s needs. The provider continued to operate a safe and robust recruitment and selection procedure to make sure staff were suitable and safe to work with people. One recruitment record and some maintenance records were not always clear or complete.
Risks were appropriately assessed and mitigated to ensure people were safe. People’s pressure areas had been appropriately recorded and treated. Equipment was in place to meet people’s needs. Medicines were managed safely. Records evidenced that people had received their medicines as prescribed.
Effective systems were in place to enable the provider to assess, monitor and improve the quality and safety of the service. Accidents and incident were monitored and lessons were learned when things went wrong to reduce the risk of it happening again.
People and their relatives were actively involved in improving the service, they completed feedback surveys and had meetings.
The service was clean and tidy. Staff used personal protective equipment to keep themselves and people safe from the risks of infection. The service had been appropriately maintained.
Staff knew what they should do to identify and raise safeguarding concerns. The registered manager knew their responsibilities in relation to keeping people safe from harm.
Staff were positive about the support they received from the management team. They felt they could raise concerns and they would be listened to.
The management team had built strong links with other local registered managers and providers who they gained support and advice from. The management team had signed up to conferences and events in the local area to help them continuously learn and improve. The provider had displayed their rating in the service and on their website and had notified CQC about important events and incidents.