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Inspection Summary


Overall summary & rating

Good

Updated 30 October 2018

We undertook an unannounced inspection of Frithwood Nursing Home on 9 October 2018. The service was inspected on 3 August 2017, when we rated the service requires improvement. We identified two repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to safe care and treatment and good governance and issued the provider two warning notices. We undertook a focused inspection of the service on 10 October 2017 to check if the provider had met the requirements of the warning notices and found they had.

Prior to this inspection, we received anonymous concerns highlighting some areas of poor practice at the home. We considered these as part of our inspection and in assessing how well the service was meeting the five key questions we asked of providers. We found that the service was rated good in all key questions.

Frithwood Nursing Home 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. The service provided both nursing and personal care and is registered to care for up to 26 people. At the time of our inspection, 22 people were living at the service. All the people were over the age of 65 years and some people were living with the experience of dementia.

The service is owned and managed by MD Homes, a partnership which also owned other similar services, mostly in North-West London.

There was a registered manager in place who had been running the service since June 2015. 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 and associated Regulations about how the service is run.

Risks to people's wellbeing and safety had been assessed, and where risks had been identified, the provider had taken appropriate action to mitigate these.

There were procedures for safeguarding adults and staff were aware of these. Staff knew how to respond to any medical emergencies or significant changes in a person's wellbeing.

Staff followed the procedure for recording and the safe administration of medicines.

The service employed enough staff to meet people's needs safely and had contingency plans in place in the event of staff absence. Recruitment checks were in place to obtain information about new staff and ensure they were suitable before they started working for the service.

There were systems in place to protect people from the risk of infection and the environment was clean and free of hazards.

The provider had sought relevant guidance and had taken steps to improve the environment to meet the needs of people living at the service and in particular of those living with the experience of dementia.

The provider was aware of their responsibilities in line with the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty safeguards (DoLS). Staff had received training on this. People’s capacity to make decisions about their care and treatment had been assessed. Processes had been followed to ensure that, when necessary, people were deprived of their liberty lawfully.

People's health and nutritional needs had been assessed, recorded and were being monitored. People had access to healthcare professionals as they needed, and their visits were recorded in people’s care plans.

People were supported by staff who received regular training and who were regularly supervised and appraised to ensure they were skilled and competent to care for people living at the service.

The provider told us they ensured that lessons were learned when things went wrong, such as speaking with staff and providing additional training as needed, to prevent reoccurrence.

We saw t

Inspection areas

Safe

Good

Updated 30 October 2018

The service was safe.

Risks to people's wellbeing and safety had been assessed, and where risks had been identified, the provider had taken appropriate action to mitigate these.

Staff followed the procedure for the recording and safe administration of medicines.

There were procedures for safeguarding adults and staff were aware of these.

There were enough staff on duty to meet people�s needs in a timely manner. Checks were carried out during the recruitment process to ensure only suitable staff were being employed.

Effective

Good

Updated 30 October 2018

The service was effective.

The provider was aware of their responsibilities in line with the requirements of the Mental Capacity Act 2005 and DoLS and understood its principles.

The provider had taken appropriate steps to improve the environment in a way to support people who were living with the experience of dementia.

Staff received training and training certificates were available to confirm this. People were supported by staff who were supervised and appraised.

People's health and nutritional needs had been assessed, recorded and were being monitored to ensure these were met.

Caring

Good

Updated 30 October 2018

The service was caring.

Staff supported people in a kind and caring way and interacted with people throughout the day.

People were supported with their individual needs in a way that valued their diversity, values and human rights.

Care plans contained people�s background and their likes and dislikes so staff could consider these when providing care to people.

Responsive

Good

Updated 30 October 2018

The service was responsive.

There were regular activities provided for people using the service. The provider had purchased new material to help meet the needs of people living with dementia.

People were consulted about their end of life wishes and these were recorded in their advanced care plans.

People's individual needs had been assessed and recorded in their care plans prior to receiving a service, and were regularly reviewed. Care plans contained enough detail for staff to know how to meet peoples� needs and were written in a person-centred way.

There was a complaints policy and procedures in place.

Well-led

Good

Updated 30 October 2018

The service was well-led.

The provider had a number of systems to monitor the quality of the service and put action plans in place where concerns were identified.

The service conducted satisfaction surveys for people and visitors. These provided information about the quality of the service provided.

Staff found the provider to be approachable and supportive.

The provider encouraged good communication with staff and people who used the service, which promoted a culture of openness and trust within the service.