The Flowers Care Home Limited

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to meeting people’s nutritional and hydration needs.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.
The provider did not have sufficiently effective quality assurance systems in place to ensure assessments of people’s needs were accurate, consistent and up to date. Management oversight and auditing processes were not effective in identifying inaccuracies or contradictions within records, and action was not consistently taken to address these issues in a timely way.
We found inconsistencies within pre-assessments for some people, which led to contradictory information within care plans and a lack of clarity about people’s actual needs. Records were not consistently reviewed following changes in need, which increased the risk that care was not always planned or delivered in line with people’s current circumstances.
As a result, staff could not always rely on care plans as an accurate source of guidance to support people consistently.
 

The provider did not ensure people received adequate nutrition in line with their assessed needs, and governance systems failed to identify, escalate or address these concerns in a timely way.
The quality of food provision was poor and did not meet people’s nutritional needs. Across all 3 days of inspection, there was a lack of fresh fruit and vegetables available, food was not fortified to increase nutritional value, and high-calorie snacks were not routinely provided to people who required them.
We found 8 people had identified nutritional needs, including recent weight loss. Four people had lost weight, and these, along with a further 4 people, were assessed as requiring fortified food to increase their calorie intake. However, we saw no evidence that food was being fortified in line with these assessments.
Although food and fluid intake charts were in place for people at nutritional risk, these were not completed accurately. Records did not specify the quantities of food provided or consumed, limiting their effectiveness as a monitoring tool. Despite charts being reviewed and signed, there was no evidence that concerns identified, such as low food intake, lack of snacks, or poor food quality- resulted in any actions being taken to improve people’s nutritional intake.
We observed people showing signs of hunger on all three days of inspection. Two people were seen attempting to take food from other people’s plates. Records we reviewed confirmed this behaviour had been occurring regularly, indicating people’s nutritional needs were not being met.
On the first day of inspection at 6:30am, we observed 9 people already up and seated in the lounge being offered tea and toast for breakfast. Although a cooked breakfast option was displayed on the whiteboard, this was not offered later in the morning. No snacks were provided between breakfast and lunch.
Lunch was served at 12 noon and consisted of 8 tins of vegetable soup to be shared between 18 people, with a slice of dry bread. An alternative option of a cheese sandwich was available. Desserts were limited to a chocolate mousse or yoghurt with spray cream. People were not offered second helpings, despite care plans for several people stating they required additional portions or encouragement to eat.
Following concerns identified during the inspection, the local authority intervened to ensure people were provided with more nutritious meals. The provider subsequently employed a cook to work until after lunchtime. However, during the inspection period there remained only 1 hot meal option available, and portion sizes and desserts continued to be limited.
 

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.
Communication between the management team and care staff was not effective. The provider had not assured themselves that communication systems and handover processes were effective and did not routinely review whether important information was shared appropriately between staff teams.
We observed handovers between night staff and day staff, and from day staff to night staff. Important information identified during the inspection was not always shared with night staff, increasing the risk that people did not receive consistent care.
On the second day of inspection, staff working the afternoon shift told us they were unclear about events from the morning shift. There were no daily records or handover notes in place, and staff had not been informed whether essential tasks, including the delivery of the weekly food shopping, had been completed.
During handovers, staff discussed that one person had missed planned healthcare appointments due to a lack of transport. There was no evidence of follow-up discussion, investigation, or action taken to understand why this occurred or to prevent a recurrence.
On the second day of inspection, district nurses were present at the service and told us the provider had not engaged with the free training offered by their team to care staff. This training would have enabled staff to safely apply simple dressings to minor wounds, skin tears or cuts until a district nurse could attend. Due to the provider’s lack of engagement, staff routinely contacted unplanned care services to request immediate attendance by district nurses for minor injuries.
 

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.
People were not consistently supported to live healthier lives. The quality and quantity of food provided did not support people’s health and wellbeing. During the inspection we observed insufficient amounts of food being provided, and until intervention by the local authority, meals were largely reliant on packet, tinned and ready-made foods rather than freshly prepared meals using fresh ingredients.
People were not consistently supported to maintain physical activity or access the local community. We found no recent records to demonstrate people were supported to go for walks or attend community groups. The service did not employ an activity coordinator, and responsibility for providing activities rested with care staff.
On the first day of inspection, the activity board stated a scenic drive would take place; however, this did not occur due to staffing levels. On the third day of inspection, we observed a chair-based exercise session in the lounge. A review of daily records showed limited evidence of meaningful or varied activities taking place. Recorded activities primarily consisted of passive engagement such as watching television, listening to music or completing a quiz.
We observed several people who were able-bodied and had the capacity and ability to complete everyday tasks, such as washing up, tidying communal areas, preparing drinks or snacks. However, staffing levels did not allow for appropriate supervision, and people were not supported to carry out these tasks safely. As a result, people were not encouraged to maintain their independence or daily living skills.
 

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.
Systems to monitor people’s health outcomes were not effective. Although clinical monitoring tools were in place, these were not consistently updated to reflect changes in people’s needs or used to drive appropriate action.
We reviewed Malnutrition Universal Screening Tool (MUST) assessments and found these identified weight loss and nutritional risk, with actions recorded such as the provision of fortified food. However, there was no evidence these actions were being implemented in practice. We did not find evidence food was being fortified in line with assessed needs. There was no evidence of management oversight or review to ensure agreed actions were followed through.
People assessed as being at high or very high risk of pressure ulcer development, as identified through Waterlow risk assessments, were not consistently monitored. Where repositioning was required, repositioning records were either incomplete or absent.
We found one person, who had been cared for in bed for approximately three weeks, did not have any repositioning records in place until 9 January 2026. Another person who had also been nursed in bed for a prolonged period had repositioning records containing significant gaps, meaning it was not possible to determine whether they were repositioned safely and in line with their assessed needs.
In addition, we identified contradictory information within care records for one person assessed as being at high risk of pressure damage. This person had developed pressure damage recently; however, records conflicted as to whether the pressure damage was still present or had resolved. This lack of clarity meant staff could not rely on records to accurately monitor the person’s condition or respond appropriately to changes.
 

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.
People and their representatives were not consistently involved in care planning or review. In almost all care plan review sections we examined, records stated that the person was “unable to sign due to illness.” There was little evidence that next of kin or other representatives had been engaged in the review or contributed to care planning.
Some relatives reported they were aware a care plan existed for their loved one; however, responses were mixed regarding whether they had been invited to participate in care plan reviews or had contributed to the recorded details. Care plans did not always provide sufficient information about people’s communication needs or preferences, limiting staff opportunities to use alternative methods to seek consent and involve people in decision-making.
Mental capacity assessments were completed for people who were assessed as lacking capacity to make decisions for themselves. However, these assessments and associated care plans did not consistently identify involvement of relatives, next of kin, or those holding powers of attorney in decisions about care and treatment.
Do not attempt CPR (DNACPR) notices were in place where agreed and were accessible at the front of care records.