The Firs Residential Home

Peoples’ experience of using this service and what we found

The provider and registered manager nurtured a culture which truly put people at its centre. Staff were unanimously positive about the registered manager and each other. All of the people and relatives we spoke with were consistently positive about the service. One relative told us, “It’s the best choice we could have made [choosing The Firs]. I have already recommended The Firs.”

Staff feedback about why they worked at the service reflected the service ethos. One told us, "I love my job. I see people here as my family and I care for people like they were my Mum or Nan." Another staff member said, "People rely on us, and the end of the day that’s why we are here. When we lose people here I get emotional as it's like losing a family member.”

The registered manager had ensured the philosophy of the service was embedded into staff practice. Signage about ‘Putting the Residents at the Heart of everything we do’ was displayed in various locations. There was a dignity tree in the hallway and the registered manager told us this was important because the service ethos was about listening to what people want. Each person was given the chance to put a quote on the dignity tree about what was important to them.

The provider and registered manager worked in partnership with other healthcare professionals to ensure people got the support they needed and were committed to continuously improving the service.

The provider and registered manager demonstrated an ability to maintain an excellent standard of care provision through effective governance and oversight. The service were part of a pilot with the local authority to achieve the best outcomes for people. The registered manager had received an award from the local authority as recognition for their commitment to making people's lives better.

The leadership at the service was distinctive and positive feedback about the registered manager. This had achieved excellent outcomes for people and staff. The service was dedicated to ensuring continuous quality improvement to enhance people's lives. The care we observed was person centred and individual to people. We spoke with healthcare professionals who were consistently positive about the service leadership, with one telling us, “From a leadership perspective she’s an example for other to follow. The Firs work so openly with and me and the standards are very high.”

People and their relatives spoke positively of the care staff and we heard of examples where staff went above and beyond to support people. People were empowered to be actively involved in the service. For example, people had been invited to design certain areas of the service and we saw plaques had been placed in these areas to identify this.

There were positive opportunities to be involved with the local community, for example the service were part of a ‘Generational Exchange’ and a ‘National Literary Project’ with the local school. A visitor told us about the positive effect on their relative.

Systems were in place to safeguard people from abuse and peoples’ risks were assessed and well monitored. People were supported to receive their medicines safely. Peoples’ care plans contained good detail about how staff could support them to manage their health conditions and the risks associated with them. Systems were in place to ensure staff were recruited safely. Disclosure and Barring Service checks were obtained. There were enough staff to ensure peoples’ needs were met and people told us staff had enough time to provide the care they needed, and to spend time talking with them.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update:

The last rating for this service was Requires Improvement (published 2 March 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

The overall rating for the service has changed from Requires Improvement to Good based on the findings of this inspection.

Follow Up:

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Firs Residential Home provides personal care and accommodation for older people. The service is registered to support up to 29 people. At the time of the inspection there were 12 people living at The Firs.

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

At our previous inspections in August 2019 and November/ December 2020 we found people were at risk because the providers governance system had not identified failings in the quality and safety of the service. At this inspection we found improvements had been made, however they were recent and still in the process of being established and embedded.

At the inspection in November/ December 2020 there were serious failings with infection control prevention measures. We took enforcement action. At this inspection there were robust infection control practices and staff were following them. An effective maintenance programme ensured the premises were safe, clean and well maintained. The environment promoted people’s independence, especially for those people living with dementia.

People told us they were happy at The Firs. The service was consistently reported to be safe by relatives who expressed confidence in the care. People and their relatives gave us positive feedback about the quality of care and staff approach. A relative told us, “The care is very good, it’s improved significantly since the last inspection, there has been a real difference.”

Risks associated with people's care had been assessed and guidance was in place for staff to follow. The service was proactive in ensuring peoples nutrition and hydration needs were met and any risks managed. Care plans were detailed, person centred and reviewed frequently with people, and their relatives where appropriate. They gave staff the information they needed to support people safely in line with their individual needs and preferences. There were systems in place to ensure information about any changes in people’s needs was shared promptly across the staff team. The service worked alongside external health and social care professionals to support people safely. Safeguarding processes were in place to help protect people from abuse.

The service had been through a challenging time due to the pandemic. Relatives and staff spoke highly of the way this had been managed. Feedback from one relative stated, “This is a home that despite the challenges it has had to embrace has worked with all outside agencies to become a well led, caring and friendly residential home. I have complete praise for all staff here, in one of the most difficult occupations and in the most difficult of times."

Staff were caring and kind and had developed positive and meaningful relationships with people. People were respected, included in decisions and their privacy and independence promoted. People and relatives were supported to express their views and had a voice in the running of the service.

The care provided was sensitive to people's diverse needs. All information was available in an accessible format, which meant people could make a meaningful contribution to their community.

Staff had worked hard to provide social and mental stimulation for people to reduce their anxiety and depression. Activities and engagement provision was person centred, consistent and showed clear positive outcomes for people. Staff supported peoples contact with loved ones as best they could given the restrictions. Relatives spoke highly of the communication they had with the service during the pandemic.

Staff were recruited safely, and there were sufficient staff on duty to meet people’s needs and spend time with them.

People received their medicines safely, and in the way prescribed for them. The provider had good systems to manage safeguarding concerns, accidents, infection control and environmental safety.

An effective induction and training programme had been developed and was being introduced. Staff told us how this helped them to do their jobs effectively. We observed some skilled practice as staff supported people living with dementia, recognising any triggers that may cause them distress, and providing the individualised support they needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Rating at last inspection.

The last rating for this service was inadequate (published 25 November 2019) and there were multiple breaches of regulation. Positive conditions were placed on the providers registration. Since this inspection CQC has received monthly action plans showing continuing improvement.

As part of CQC's response to care homes with outbreaks of coronavirus, we carried out a targeted inspection on 27 November and 14 December 2020. This looked at infection prevention and control measures under the Safe key question. We found evidence that the provider needed to make improvements. An urgent condition was placed on the providers registration. Targeted inspections do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections cannot change the rating from the previous inspection. This is because they do not assess all areas of a key question. This resulted in an inspected but not rated outcome.

This service has been in Special Measures since 23 October 2019. At this inspection we found there had been good, sustained improvement. This stemmed from robust overall governance which was in the process of being embedded. Previous breaches of regulations had been met. The service is no longer in 'special measures'. The service has demonstrated improvements and is no longer rated as inadequate for any of the five key questions. The conditions on the providers registration have also been fully met. These relate to governance; care plans and risk assessments; staff training; people at risk of weight loss; the provision of individualised social activities; obtaining people’s views and infection prevention and control.

Why we inspected

This was a planned inspection based on the previous rating.

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 coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

The Firs Residential Home is a care home. It is registered to provide accommodation and personal

care for up to 38 older people. Bedrooms are situated over two floors with communal areas on the ground floor. The service supports people living with dementia, a mental illness, and/or a physical disability. Nursing services are provided by the community nursing team. On the second day of inspection there were 18 people living at the service.

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

People were at risk because sufficient measures were not in place to prevent the spread of infection.

Staff did not always use personal protective equipment in line with UK government guidance, and where they did use it they did not always do so correctly. For example, we observed staff members wearing their face mask on their chin while taking a break and then using the same mask when returning to their shift. Some staff did not know when they should be wearing a mask, gloves or an apron and we saw staff members not wearing masks when they should have been.

Clinical waste was not always stored or disposed of safely and in a way which minimised the risk of cross contamination.

There were not enough staff available to ensure the enhanced cleaning required by current UK government guidelines took place, and records in place did not reflect these guidelines. There were several occasions where there were no domestic staff on duty and no record of any cleaning being done. There was limited provider oversight of infection control procedures and these issues had not been identified.

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 Inadequate (published 26 November 2019) with multiple breaches of regulation. We did not review these breaches during this inspection.

Why we inspected

As part of CQC’s response to care homes with outbreaks of coronavirus, we are conducting reviews to ensure that the Infection Prevention and Control practice was safe and the service was compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We looked at infection prevention and control measures under the Safe key question.

We have found evidence that the provider needs to make improvements. Please see the Safe section of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Firs Residential 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 breaches in relation to infection control at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Firs Residential Home is a care home. It is registered to provide accommodation and personal

care and accommodation for up to 38 older people. The service supports people living with dementia, a mental illness, and/or a physical disability. Nursing services are provided by the community nursing team. At the time of the inspection there were 28 people living at the service.

The service is on two floors, with access to the upper floor via stairs or a shaft lift. All bedrooms have ensuite facilities. There is an outside shared patio area.

At the time of our inspection the local authority adult safeguarding team were investigating allegations of poor care, and the service was being supported by the local authority quality and improvement team. Because of the concerns identified the provider decided to voluntarily suspend all new placements to the service until improvements were made.

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

The providers overall governance framework to help identify where improvements were required had been ineffective. The systemic failings found at this inspection demonstrated the provider had failed to ensure people received a well-managed service which was safe and compassionate; placing people at risk of potential and continued harm.

Since our last inspection, the ratings for all key questions had deteriorated.

People told us they felt safe living at the service. However, not all practices were safe enough. People were supported by staff who had been recruited safely. However, people expressed there was not always enough staff to meet their needs. The manager was actively recruiting for new staff, but in the meantime was using temporary agency staff to cover staffing vacancies. We found the reduction of permanent staff was impacting on the service, as the high use of agency staff meant new systems and processes were not always communicated or embedded.

Risks associated with people’s care were not always documented and/or known by staff. This meant there was a risk people received unsafe or inconsistent care. People’s medicines were managed safely.

People lived in a clean environment and were protected from the spread of infection. The environment had been assessed for safety.

Some people were supported with some aspects of choice and control in their lives. Overall, staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were unsatisfied with the quality of meals provided and did not receive a positive dining experience. Overall, people had their health care met in a personalised way but told us, they did not feel fully involved in their care and support. Records were not always in place to describe to staff how people wanted their health and social care needs to be met.

People and relatives told us staff were kind and caring and overall, people’s privacy and dignity was promoted.

Social opportunities existed, however during our inspection people sat all day in the lounge, without any stimulation, with two people walking up and down the corridors. In addition, it was not detailed in people’s care plans or from our observations, how social care was being individually planned.

Overall people and staff told us the service was well managed. The culture of the service was developing as the new manager continued to make required changes; some of which were causing discontentment within the staff team. There were ineffective monitoring checks in place, however a new system was being developed and implemented.

People did not always have confidence in the complaints process and were not involved in the ongoing development of the service.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We recommended the provider refers to the Commissions ‘smiling matters, oral health care in care homes’ to help strengthen people’s oral health care plans. We also recommended that the providers governance processes includes the effective monitoring of people’s mental capacity and status of DoLS applications.

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

Rating at last inspection (and update)

The last rating for this service was Good (Published 28 July 2018).

Why we inspected

The inspection was prompted due to concerns received about people’s care and safety, infection control, staffing and management and leadership. A decision was made for us to inspect and examine those risks.

We have found evidence the provider needs to make improvement. Please see the safe, effective, caring, responsive and well-led sections of this full report.

The manager had and continued to act to mitigate ongoing risks where needed.

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

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

Special measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The inspection took place on the 28 June 2017 and was unannounced. The Firs Residential Home provides care and accommodation for up to 38 older people, some of whom are living with dementia. On the day of the inspection 35 people lived at the home.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 2008 and associated Regulations about how the service is run.

One person said when asked; “Safe- of course. Why wouldn’t I be?” A relative said; “Yes she is safe.” Professionals spoken with all felt people were safe living in the service.

People were engaged in different activities and enjoyed the company of the staff. There was a calm and relaxed atmosphere within the service. People said they were happy living at the service.

People were satisfied with the care the staff provided. They agreed staff had the right skills and knowledge to meet their needs. People were encouraged and supported to make decisions and choices whenever possible in their day to day lives.

People were protected from harm as staff had completed ‘safeguarding of vulnerable adults’ training. Staff understood how to report any concerns and what action they would take to protect people.

People who did not have capacity to make decisions for themselves were supported by staff to make sure their legal rights were protected. Staff worked with other professionals in people’s best interests. The registered manager worked in the service most days and had taken action where they thought people’s freedom was being restricted. Applications were made and advice sought to help safeguard people and their human rights.

People were protected by safe recruitment procedures. Staff were supported with an induction and ongoing training programme to develop their skills, and staff competency was assessed. People, staff and relatives said there were sufficient staff on duty.

People had their privacy and dignity maintained. Staff were observed supporting people with patience and kindness.

People had visits from healthcare professionals. For example, speech and language therapists, to ensure they received appropriate care and treatment to meet their healthcare needs. Professionals confirmed staff followed the guidance they provided. People received the care they needed to remain safe and well. For example, people had regular visits by district nurses to attend to dressings. People’s end of life wishes were documented and respected.

People’s medicines were managed safely. Medicines were stored, and disposed of safely. Senior staff administered medicines. They confirmed they had received training and understood the importance of the safe administration and management of medicines.

People were supported to maintain a healthy balanced diet. People told us they enjoyed their meals and there was plenty of food available. We observed people, who required it, being supported at mealtimes. One person said; “The food is exceptional!”

People’s risks were considered, well-managed and regularly reviewed to help keep people safe and well. Whenever possible, people had choice and control over their lives and were supported to engage in activities. Records were updated to reflect people’s changing needs. People and their families were involved in the planning of their care. People’s care records were of a good standard, were detailed and recorded people’s preferences.

People said the registered manager was very approachable and made themselves available to them. Visiting professionals and staff confirmed the registered manager made themselves available and were very good at supporting them. Staff talked enthusiastically about their roles and took pride in their work.

The registered manager and registered provider had an ethos of honesty and transparency. This reflected the requirements of the duty of candour. The duty of candour is a legal obligation to act in an open and transparent way in relation to care and treatment.

People’s opinions were sought formally and informally. There were quality assurance systems in place. Feedback was sought from people and their relatives to assess the quality of the service provided. Audits were conducted to ensure the quality of care and environmental issues were identified promptly. Accidents and safeguarding concerns were investigated and where there were areas for improvement, these were shared for learning.

Audits on infection control had taken place. Staff had received training in infection control.