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Inspection Summary

Overall summary & rating


Updated 1 November 2017

This inspection took place on 22 and 23 August 2017 and was unannounced on the first day. We returned the following day to complete this and we gave the provider notice of this.

Fridhem Rest Home provides accommodation and personal care for up to 25 older people, some of whom may be living with dementia. There were 21 people living at the home when we visited.

There was a registered manager working at the service. 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 of the Health and Social Care Act and associated Regulations about how the home is run. Two managers run the service, who are also owners of the business, one of them is the registered manager. The registered manager was not available on the first day of the inspection, however, the other home manager was. We met with the registered manager on the second day of the inspection.

We last inspected the service in June 2016 and found some shortfalls in the service provided. The provider was not meeting the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At that inspection, we also found that the systems in place to monitor or assess the quality and safety of the service provided were not effective. Accidents and incidents were logged, but analysis of this information was not completed which could identify any emerging themes or trends.

We asked the provider to provide an action plan to explain how they were going to make improvements to the home. At this inspection, we found that improvements had been made.

Staff knew how to keep people safe from abuse. Staff were confident that if they had any concerns they would be addressed quickly by the registered manager. Risks to people had been assessed and regularly reviewed. Actions had been taken to mitigate these where necessary. Checks had been made on the environment to ensure the service was safe. Equipment to support people with their mobility, such as hoists had been checked to ensure people were safe.

There were enough staff to ensure people were safe and had their needs met in a timely way. Medicines were stored safely, people received their medicines when they needed them

Staff received training to make sure they had the skills and knowledge to carry out their roles. Specialist training such as diabetes and supporting people living with dementia had been completed.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

Staff understood their responsibilities under MCA, people’s capacity had been assessed and when required best interests meetings had been held and recorded. Staff encouraged people to make decisions about their day-to-day care and remain as independent as possible.

People told us that they enjoyed the food. People had a choice of meals and were supported to maintain a healthy diet in line with their choices, preferences and any healthcare needs. People’s health was assessed and monitored. Staff took prompt action when they noticed any changes or decline in health. Staff worked closely with health professionals and followed guidance given to them to ensure people received safe and effective care.

People’s dignity and privacy was maintained by staff. People told us staff were kind and caring. Staff spent time with people and were genuinely interested in them and what they wanted t

Inspection areas



Updated 1 November 2017

The service was safe.

Potential risks to people were assessed and there was guidance for staff on how to reduce risks. Staff knew how to keep people safe and how to recognise and respond to abuse.

People received their medicines safely and on time. Medicines were stored and managed safely.

There were enough staff to meet people�s needs. Staff were recruited safely.



Updated 1 November 2017

The service was effective.

Staff completed regular training, had one to one meetings and an annual appraisal to discuss their personal development.

People were supported to make decisions. Staff understood the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards.

People�s health was assessed, monitored and reviewed. Staff worked with health professionals to make sure people�s health care needs were met.

People had enough to eat and drink and enjoyed a choice of meals.



Updated 1 November 2017

The service was caring.

Staff were compassionate and kind. They promoted people�s dignity and treated them with respect.

Staff knew people well and knew how people preferred to be supported.



Updated 1 November 2017

The service was responsive.

Each person had a care plan, which centred on them and their wishes. People told us they had been involved in planning their care if they wanted to be. Care plans were reviewed regularly.

There was an extensive range of activities on offer for people to enjoy.

People knew how to complain. Complaints received had been responded to and resolved in a timely manner.



Updated 1 November 2017

The service was well-led.

People, relatives and staff were asked their views on the service provided.

There was an open and transparent culture. People, relatives and staff were encouraged to make suggestions to improve the service.

Effective audits were completed. Actions were taken when shortfalls were identified. The managers had a continuous development plan for the home.

Notifications had been submitted to the Care Quality Commission in line with guidance.