Friary 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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment, safeguarding and staffing.

This service scored 31 (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 have a proactive and positive culture of safety based on openness andhonesty. They did not listen to concerns about safety and did not investigate or report safetyevents. Lessons were not learnt to continually identify and embed good practice.

Monthly quality audits of incidents and accidents were not completed, which meant the provider was unable to identify any patterns of incidents to implement effective risk mitigation measures. The provider told us they planned to start these. We found no evidence that people were involved in or consulted about reviews of concerns, accidents, incidents and adverse events or in planning to prevent similar incidents in the future. This meant people were at risk of re-occurring harm and improper treatment. We also found no evidence that learning from accidents and incidents had been effectively shared with the staff team, or that care plans and risk assessments had been updated to reflect new learning, or ways to mitigate risk and promote safe, person-centred support.

The registered manager told us that they learnt from incidents, “An example of this would be that a resident fell in their bedroom recently but was unable to reach the call bell and we didn’t act as quickly as we normally would. As a result, we have ordered and put in place monitors that automatically alert us if someone gets up so that we can act quickly without relying on the residents being able to use the call bell, these alerts use infrared to detect when a resident stands up or moves unaided.” We saw no record of this learning and how it was shared with staff and people.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People did not have hospital passports in place when required. These documents support people when they move between services such as admission to hospital. They contain important information such as people's individual communication needs. This placed people at risk of harm of not having their needs met.

The registered manager told us, “We have a ‘fall in care homes’ protocol from the local GP that we must follow. We are also taking part in a trial with one of the frailty nurses where we will monitor fluid intake on our residents and record any urine infections or falls during a specific period.”

A healthcare professional told us “from the perspective of [the team], they engage very well with us both for routine and urgent issues, following protocols we have in place and always seeking advice in an appropriate and timely way. They also ensure that any medical advice we are giving is followed promptly and accurately, and when we request information from them, it is provided in a timely way.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff, including the registered manager failed to identify and report abuse when providing care and treatment. They failed to understand their individual responsibilities to respond to concerns about abuse when providing care and treatment, including investigating concerns meeting timescales for action, or the local arrangements for investigations. At the request of inspectors, the service reported safeguarding incidents retrospectively to the local authority during the inspection. This meant people remained at risk of harm and opportunities to mitigate risks had been missed.

However, people and their families told us that they felt safe at Friary House. A person told us, “I really do feel safe I cannot fault it.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not always complete risk assessments that balanced the needs and safety of people using the service and failed to share assessments and care plans with other organisations to ensure continuity of care. For example, the risk of choking, contractures or skin integrity breakdown were not effectively managed. Appropriate referrals to healthcare professionals were not always made when needed, and instructions from healthcare professionals were not always recorded in people’s care plans and risk assessments. This placed people at risk of receiving incorrect care.

Safe swallowing plans devised by the Speech and Language Therapy Team (SALT) for people with swallowing difficulties were not mentioned in people’s care plans, and staff had not been made aware of safe swallowing requirements for people. Staff were working with limited guidance and were not supported to help mitigate risks to people; leaving them at risk of harm from aspects of their health and other conditions such as swallowing difficulties, contractures and skin integrity issues.

We reviewed the epilepsy care plan for a person, which provided staff with limited guidance on how to support the person. We found no evidence of records monitoring the persons epileptic seizures to establish possible triggers, trends or patterns. This placed the person at increased risk of developing complications due to epilepsy.

A family member told us, “[Person] is reviewed by a member of the frailty team regularly. Staff have accompanied [them] to hospital appointments in the past when family have been unable to”.

We found some people who had been identified as at high risk of skin integrity breakdown had their air mattresses set incorrectly for their weight. We also found management and staff were not certain who required skin repositioning and when. We requested repositioning charts, but these were not provided. However, we found evidence of inconsistent recording in the daily notes which showed staff were not following the care and support plan in place. This placed people at increased risk of skin integrity breakdown, putting people at risk of harm.

Peoples’ Personal Emergency Evacuation Plans (PEEP) and care plans did not always include accurate and up to date information about fire risks or how to support the person to evacuate. The risks associated with use of potentially flammable creams and emollients had not been assessed.

Feedback from staff was not consistent, some felt they had enough information about peoples risks and others felt more training was required, such as training in epilepsy, behaviours that challenge, skin integrity and diabetes. Therefore, people were at risk of being supported by staff who were not trained to meet their needs safely.

People and relatives provided mixed feedback as to whether they had been involved in creating assessments of people’s health, safety and welfare. We received comments such as, “Yes we are aware, and we are included in reviews” and “I have never asked for a care plan.” A person living at Friary House told us they had never seen their care plan.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found 2 peoples bedroom windows did not have window restrictors in place and the opening latch of 1 of the windows was not in working order. This placed people at risk of falling from height.

We saw records of equipment testing including, the fire alarm system, fire extinguishers and emergency lighting. Fire risks had been identified in a fire service assessment of the premises however, we found no evidence that all actions had been completed to rectify these risks. The registered manager told us they did not know where the fire action plan was and that they would have to speak to the maintenance person regarding what actions had and had not been completed.

There was no water hygiene risk assessment in place during our on-site inspection and regular internal water hygiene checks to ensure peoples safety had not been completed. These checks ensure that water is clear of harmful bacteria such as legionella. A water hygiene risk assessment was completed during our assessment and identified required remedial actions.
Risk assessments relating to the health, safety and welfare of people using the service were not in place. For example, control of substances hazardous to health (COSHH) and infection prevention control (IPC) risk assessments were not in place. This placed people at risk of harm from exposure to dangers within the environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Recruitment processes were not robust, and systems were not in place to monitor the process to ensure staff had been recruited safely. We reviewed the recruitment files of 3 staff members. We saw no evidence that staff files contained health questionnaires. Disclosure and Barring Service (DBS), employment history gaps, references and other recruitment checks had not been carried out appropriately. This meant that recruitment checks were minimal, and signs of unsuitability were not always given due attention. The registered manager told us, “We have not updated our DBS checks as the staff sign to state that if they have any criminal involvement then they must inform the company. We have made the decision as a company to redo all DBS checks and to make them portable so that all DBS are current.”

Supervision was not in place for 1 of the 3 staff members. The other 2 staff members had participated in 1 supervision in the last year. The providers service improvement plan stated supervisions should be completed with staff 3 times per year. The registered manager told us there was no supervision matrix in place, and they usually completed the supervisions about the same time.

The training matrix was updated during our inspection. The updated training matrix showed staff training was not completed and updated in line with best practice guidance from Skills for Care. The registered manager told us, “I monitor the staff training by ensuring that all the staff members are put on mandatory training when they first start and are booked onto refreshers on a three yearly basis.” The training compliance matrix showed that not all staff had completed appropriate training for their roles. For example, fire, safeguarding, infection control, moving and handling, health and safety, end of life and palliative care, mental capacity and Deprivation of Liberty Safeguards (DoLS). We found 1 member of staff had been supporting people with moving and handling without having completed moving and handling training. The training matrix did not include all training required to meet peoples’ needs safely and effectively. For example, there was no training in epilepsy, stroke, skin integrity, dysphasia, or mandatory training such as dignity and respect. Staff training was inconsistent, and there was a lack of monitoring.

In addition, medication administration and moving and handling competency assessments had not been completed. The provider booked training courses during the inspection. However,because staff were not suitably trained people, especially those with complex care and support needs were at risk of receiving unsafe and inconsistent care.

The registered manager told us they used a dependency tool to calculate the number of staff needed to provide safe care. However, the dependency tool used had not been effective to assess the needs of people using the service. For example, the dependency tool did not take into consideration medicine administration and the repositioning of people.We reviewed 4 weeks of staff working rotas. We found on numerous days there were not a sufficient number of staff deployed to meet people needs.

Feedback from staff was mixed. One staff member told us, “I do feel like we get enough training for people's complex needs and if there is a need for any more training we can go to our manager, and she will find a relevant training course for us. We have regular supervisions with our manager and there is an open-door policy so we can go to our manager whenever we need to for support.” Other staff members told us that they felt that they required more training and though they had regular chats with the manager they had no formal supervision. Some staff members told us they felt more staff were needed.

Relatives felt there were enough staff on duty, and people told us that staff came relatively quickly when they used their call bells. While people and relatives expressed a general satisfaction with the care, our assessment found elements of care did not meet the required standards.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Therefore, people were at risk of harm due to a lack of good practice and oversight of infection risks.

The service carried out hand washing audits. However, clinical waste bins were not in place in all bathrooms. We found clinical waste bags left on a commode in a communal bathroom. Mops were left in communal bathrooms, and the mops were not colour coded to reduce cross contamination. Cleaning schedules had gaps in recording. There was no infection prevention and control risk assessment.

A person told us it was, “clean everywhere” and another person told us, “Sometimes the top floor gets missed, toilets are cleaned every day.”

The registered manager told us that by observing staff practice they would be able to identify if additional infection prevention control training was required.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in their creating their medicine care plan.

Medicines were not managed safely. We found medicines that were no longer needed or that had belonged to people who had died were still at the service. They were stored in the medication room, the controlled drugs cabinet and the refrigerator. It is essential medicines are disposed of in accordance with guidance and regulations.

We reviewed medicines administration records (MAR) for 3 people and found prescribed medicines had not been recorded in line with the provider’s medicines policy. We found gaps in recording on MARs which were not identified or investigated by the provider following audits. PRN (as and when required) protocols were not in place. This meant people may not always received their medicines when they need them.

We found information recorded by staff on MAR’s did not always match medicines labels. Start dates, allergies and dates of administration were not always recorded on MARs. Some medicines had no dosage and specific instruction for administration and were not always included on the MARs. This meant people may receive an incorrect dose of their prescribed medicines.

Best practice guidance was not followed for the use of transdermal patches. For example, the record of application did not include recording the specific location on the body where the patch had been applied. Continual use of the same area of application may cause irritation or skin breakdown.

Medicines were stored in the medicines room, and in 3 trolleys secured to a wall on each floor of the service. We found no evidence that the temperature in any medicines storage areas waschecked or recorded in line with both the providers policy and best practice guidance. There was no evidence medicines refrigerator thermometers, had ever been re-set, and the registered manager confirmed this. This placed people at increased risk of receiving medicines that may be less effective due to being stored at unsuitable temperatures.

A person told us that they administered their own medicines. A relative told us that medication changes were not always communicated to them.

Staff told us that if there was a medication error that they would tell the manager. However, staff had failed to identify and report the medicine errors we had found during our inspection, for example gaps in recording on MARs.