Frenchay House

On this page

• 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 good. At this assessment the rating has changed to 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.

We assessed all the quality statements within the key question of safe. We found the service was in breach of a legal regulation in relation to the premises and equipment. Although managers detected potential risks in the environment, timely changes or improvements had not always been made. There was damage to parts of the building and equipment which presented safety risks. For example, damaged flooring and a broken stairlift. The provider did not always effectively assess or manage the risk of infection.

Systems, processes and practices at the service had not always safeguarded people from harm. However, staff were knowledgeable about safeguarding principles. Managers were updating risk assessments were being updated and these helped staff to know how best to support people to keep them safe. People and some relatives did not believe they had been involved in reviewing risk assessments or care plans.

Medicines were managed safely in line with national guidance. Staff received training to keep people safe, such as fire safety, moving and handling and the use of different types of equipment. Managers had acted to ensure lessons were learned following accidents or incidents.

We received mixed feedback about whether there were enough staff to safely support people, although the numbers of staff on shift reflected the provider’s assessment of need. Staff were recruited safely, and checks were carried out before new staff started working at the service to confirm they were suitable to care for people.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not always a proactive and positive culture of safety based on openness and honesty. For example, staff had not always reported incidents to managers. This had been affected by several changes at the service, however training was being provided, and the new management team were keen to learn lessons and make changes at the service. There was ongoing contact with the local authority safeguarding team to facilitate improvement.

The provider had systems to record incidents and identify concerns, investigate and learn from these to reduce and manage risks. Accidents and incidents had been discussed in a recent staff meeting to support learning and reflect on practice. Staff were also being reminded how important it was to report all concerns to ensure lessons could be learned to identify and embed good 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 aimed to ensure there was continuity of care, including when people moved between different services.

When people planned to move to the service, their needs were assessed before they arrived at the home and staff reviewed these regularly. This helped to ensure people’s needs could be safely met. However, some people came to stay at Frenchay House for a shorter period of time to allow further assessment of their needs following a hospital stay. Sometimes the information which was received by the service did not provide enough detail about individual needs. The management team were addressing this.

Relatives and professionals told us communication was not always effective because staff did not always answer the telephone. This was a significant concern for some when updates were required. The registered manager told us changes had recently been made to the system to improve this.

Although the provider aimed to work with people, relatives and healthcare partners to keep people safe, other stakeholders had found the systems, processes and practices at the service did not always support the delivery of a good level of care. Multi-agency meetings were held to monitor safeguarding issues, and an action plan supported the service to prioritise and make changes. The provider had shared concerns with CQC as necessary.

Staff told us they had attended training, and they understood their responsibilities in relation to safeguarding people. They were able to describe different types of safeguarding concerns, and one staff member said, “I would escalate concerns, and if my voice wasn’t being heard would go to CQC or external authorities, like the police. I wouldn’t walk away, and I wouldn’t see a hair harmed on someone’s head.”

Staff had assessed people’s mental capacity and decisions which were made in the individual’s best interests were documented. When people were subject to restrictions to keep them safe, staff monitored these to ensure they remained necessary and proportionate. The registered manager told us some people were supported by advocates to ensure their rights and wishes were heard.

We received mixed feedback about people’s involvement in managing the risks they might face. The registered manager told us people, or their relatives were involved in reviewing individual needs and risks to ensure the care provided was safe and relevant. Most people were not able to tell us about their involvement in this process, but they did describe ways in which the team had taken actions to keep them safe. For example, 1 person wanted to iron their own clothes, but they knew they had to do this in the laundry room and not in their bedroom to reduce risks. However, 1 relative felt the risk assessments for their family member were insufficient. We discussed their specific concerns with the registered manager and saw copies of the risk assessments and management plans staff used to minimise risks to this person.

Risk assessments relating to the health, safety and welfare of people using the service were being reviewed and updated at the time of our assessment. This was to make them more detailed and specific. These assessments helped staff to know how best to support people to manage specific risks and keep them safe. For example, we saw risk assessments relating to falls, specific medical needs and accessing the community. These were detailed and up to date.

Although some people were known to express their emotions in ways which could be challenging or risky to others, staff did not always supervise people in communal areas. For example, we were advised 1 person could be aggressive to others, but they were often unsupervised by staff in the dining room with other people who lived at the service. When staff had to complete other tasks around the building, risks to people could be increased.

The provider did not always make sure that equipment and facilities supported the delivery of safe care. Building and fire safety checks were carried out and managers carried out a daily walk around the building to identify concerns and check safety. Although managers detected potential risks in the environment, timely changes or improvements had not always been made. People and their relatives highlighted concerns such as damaged flooring, walls and equipment. We were told that a stairlift had not worked for some time. Staff and relatives told us, “The stairlift is forever breaking down.” Although a lift was available to access upper floors, the layout of the building meant some routes were indirect or not accessible for everyone. Some relatives told us they were unable to use the communal lounge because there were steps into the room and the ramp was ‘never available’ or ‘too difficult’.

Paint was flaking and walls were damaged in some rooms and there were signs of mould in a bathroom. Managers were aware of these concerns, and a maintenance and redecoration programme was in place. We saw bedrooms being redecorated and there was a clear plan to make further improvements to the dining room and secure outdoor space.

One person who spent much of the day in a wheelchair did not have a cushion to relieve pressure, and another person’s relative told us, “They can never find a wheelchair if we want to take [Name] out. Wheelchairs do not have footrests or armrests sometimes, so the chairs are never complete. There is never a cushion for the wheelchair.”

Staff received training to keep people safe, such as fire safety, moving and handling and the use of different types of equipment. Staff were aware of what to do in the event of a fire and took part in regular fire drills.

People, relatives and staff did not always feel there were enough qualified, skilled and experienced staff. Several people told us they often had to wait for staff to support them, and said staff had a lot to do. One person said, “There are not enough staff, and extra staff are needed at night. It isn’t enough now.” However, another person told us, “There are enough staff. I don’t think anything needs improving.”We reviewed staff rotas and a tool used by the service to calculate the staff required to safely support people. The numbers of staff on each shift reflected the needs which had been assessed by the provider.

During our visits to the service, we saw staff working together to respond to people’s needs and requests. However, they appeared to be busy and task focused. Staff told us they did not have enough time to spend with people. One staff member said, “There’s not enough of us. The care would be better if there were more of us.”

People and relatives also noted that there had recently been a high staff turnover recently. Professionals raised concerns that recent changes meant, “There is clear strain on remaining staff. I worry about burnout amongst staff and the impact that this is having on care.” Another professional told us, “I hear every time I am in Frenchay house how unhappy the care team are, how overstretched they are, how unsupported they feel. It appears they are continually short staffed.”

The management team were taking action to make changes, but the provider had not always made sure staff received effective support, supervision and development. Some staff told us they had not received individual supervision with a senior staff member for over 1 year. Others did not feel supported by the management team on a day-to-day basis. One staff member said, “We don’t see the managers. Sometimes we need help, but they’re not around.”

Staff were recruited safely by the provider, and relevant checks were carried out before new staff started working at the service. This included criminal record and employment checks to confirm staff were suitable to care for people.

The provider did not always effectively assess or manage the risk of infection. During our visit to the service, we found areas of the home which did not meet required cleanliness standards. For example, some parts of the home smelled strongly, and other areas were cluttered or difficult to clean. Cleaning schedules were not completed consistently by staff. This meant staff could not always identify risks or take measures to make improvements or prevent and control the potential spread of infection.

Personal protective equipment [PPE] was available, although sometimes we found supplies had run out or were not stored in dispensers. For example, some hand sanitiser dispensers were empty, and paper towels or toilet paper not in dispensers. We saw staff using PPE to carry out personal care and at mealtimes.

Concerns about the monitoring and control of food safety had been identified by the local authority food safety team. They served a Hygiene Improvement Notice under the Food Safety and Hygiene (England) Regulations 2013 on 3 March 2025. Areas for improvement included consistency in safe food transporting procedures, temperature checks and the management of allergens. However, by 18 March 2025, the food safety team were satisfied that these concerns had been addressed, and a notice of compliance was received by the provider. This showed action had been taken promptly and effectively to make improvements and embed these into daily practice. The provider was committed to ongoing improvements to ensure food safety and quality.

The provider aimed to ensure medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff stored medicines securely and regularly checked them to identify concerns or address any shortfalls. Medicines which needed additional security were safely managed. During our visit, we found some gaps in medicines administration records. We highlighted these issues to the deputy manager, who took action to resolve the shortfalls. Improvements were ongoing, for example, the management team had a plan to provide training to ensure more staff were competent to manage and administer medicines.

Some people managed aspects of their own medicines, and risk assessments provided guidance to enable staff to support them as necessary. Some people took medicines such as pain relief ‘as and when needed’ (PRN). PRN protocols described why and when a person might need additional medicines, and the guidance was clear and up to date. People had regular contact with a GP and other specialist health professionals. This helped ensure medicines were regularly reviewed and continued to meet people’s needs.