Fridhem Rest Home

Updated 8 February 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 20 January 2022 and was unannounced.

Updated 8 February 2022

About the service

Fridhem Rest Home is a residential care home providing personal care to 23 people at the time of the inspection. The service can support up to 25 people. The home was supporting older people some of whom were living with different forms of dementia. The service is over two floors.

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

There were some really positive aspects to the care people received at the home, it was clear staff and the management team had worked hard during the pandemic and had continued to do so. But there were also some shortfalls which could place some people at the potential risk of harm.

The registered manager and management team were not routinely assessing the risks which people faced and considering how to manage these risks. When plans were made to manage some risks, these were not complete.

The registered manager and management team were also not assessing some risks associated with COVID-19. This included when they took action contrary to government advice. There were no risk assessments completed, advice had not been sought from professionals and the local authority and plans had not been made to manage these risks. Placing people, staff, and the service itself at risk.

Timely actions had not been taken to promote people’s safety in response to potential fire risks. Essential staff recruitment checks were not completed. With no further action from the registered manager to try and manage this issue. We also identified shortfalls with the management and auditing of people's medicines.

The management and provider of the service was not effectively assessing, and auditing key aspects of the care provided. When audits were completed these were lacking in information to demonstrate a thorough and effective audit had been conducted.

People spoke positively about living at Fridhem Rest Home, one person said, “You wouldn’t get better than here, I count myself lucky everyday for living here.” Another person said, “The staff look after us very well. We can do whatever we want to do.” A person’s relative said, “I’m always made to feel welcomed and there’s always tea and biscuits.”

There was a positive culture at the home. People felt they were well looked after and had formed friendly relationships with the staff. The staff spoke well of the support they received from each other and the leadership of the home.

The registered manager had made improvements to the home to improve people’s experiences of living at the Fridhem Rest Home.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 1 November 2017).

Why we inspected

This was a planned inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Fridhem Rest Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified three breaches of the regulations in relation to the leadership of the home and promoting people's safety. Some aspects of people's safety were not being managed appropriately. There was a lack of effective oversight and processes in place to assess and monitor the quality and safety of the service. Staff recruitment checks were not complete to ensure people were safe around staff.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.