Frindsbury Hall Care Home

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.

The service was in breach of legal regulation in relation to people’s safe care and treatment
 

This service scored 59 (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 have a proactive and positive culture of safety where learning from incidents was consistently embedded into practice.
Incidents and accidents had been recorded; however, records of “lessons learned” lacked depth and analysis. There was limited evidence that themes had been identified or that learning had been embedded into practice. Actions recorded following incidents did not consistently demonstrate how risks had been reduced or prevented from recurring.
Staff were able to describe how they would report incidents and raise concerns, and said they felt able to do so. However, there was less evidence that staff received feedback on incidents or that learning was consistently shared across the service.
 

The provider had systems in place to support safe care; however, these were not always used consistently to ensure continuity and coordination of care.

People’s needs were assessed prior to admission to ensure the service could meet them safely. Arrangements were in place to support coordination across different areas of the home, including a staffing structure where each floor had a consistent team of nurses, senior carers and care staff. This supported day-to-day continuity and helped people and visitors know who to approach for assistance. Electronic systems were available to record care plans and support communication between staff, including during handovers. These systems could also be used to share information with other services, such as hospitals, when required.

However, these systems were not always used consistently in practice. Staff described relying on verbal handovers and their own knowledge of people rather than routinely accessing care records. This meant information was not always recorded and shared through a single, reliable source. This reduced assurance that important information would always be consistently communicated or available to all staff, particularly during periods of transition or when staff were unfamiliar with people’s needs.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff demonstrated a good understanding of safeguarding processes and were able to describe how to recognise and report concerns. Where concerns had been identified, there was evidence that appropriate referrals had been made. People and relatives told us they felt safe and had no concerns about how people were treated. Observations during the inspection showed that staff supported people in a respectful and appropriate manner. Systems were in place to monitor safeguarding concerns, and information was shared with relevant agencies when required.

The provider did not always ensure risks were consistently managed through clear and person-specific care planning.
Staff demonstrated awareness of risks in practice and were able to describe how they supported people safely. However, care plans did not always provide clear guidance to support consistent management of risks. For example, where people were assessed as being at risk of falls or requiring support with mobility, care plans did not always clearly describe the level of assistance required or specific preventative measures staff should follow. In some cases, guidance was general, such as “assist with mobility,” without specifying how this should be done safely.
Similarly, for people with risks associated with eating and drinking, care plans did not always clearly describe how staff should support people safely, such as positioning, supervision levels or signs of concern to monitor.

Behavioural risks were not consistently managed in a proactive or person-centred way. Records showed that behavioural monitoring tools, such as ABC charts, were completed; however, these did not consistently identify underlying causes or triggers for behaviour. For example, incidents of distress and aggression were recorded without meaningful exploration of potential unmet needs or clear actions to prevent recurrence. This meant that while behaviours were documented, there was limited evidence that care was adapted to reduce risk, resulting in repeated incidents. This increased the risk of ongoing distress for people and potential harm to staff. This lack of detailed and specific guidance meant staff were required to rely on their own judgement and experience rather than structured instructions.

Overall, while risks were identified, systems did not always ensure that these were effectively understood or mitigated. This meant care was not always delivered in a way that consistently reduced risks and protect people from avoidable harm.
 

The provider ensured the environment and equipment supported safe care.
The environment was clean, well maintained and suitable for people’s needs. Equipment was available, appropriately stored and appeared to be in working order. People and relatives described the environment as safe and secure. Minor issues identified during the inspection were addressed promptly and did not present a risk to people. Overall, the environment supported the delivery of safe care.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.
Staffing levels were sufficient to meet people’s needs. Observations confirmed that staff were available to support people in a timely way and were not rushed in their interactions.
People and relatives told us there were enough staff, although a small number noted that response times could occasionally vary during busy periods.
Staff demonstrated knowledge of people’s needs and were able to describe how they supported individuals safely. There was a stable staff team which supported continuity of care.
Recruitment processes were safe and robust, and appropriate pre-employment checks were carried out to ensure staff were suitable to work with people using the service.

The provider had not always ensured that risks relating to infection prevention and control were consistently identified and mitigated.
The environment was generally clean and hygienic, and staff followed appropriate infection control practices. Personal protective equipment was available and used appropriately. Cleaning schedules were in place, and people and relatives told us the service was clean.
However, some aspects of the environment did not support effective infection control. For example, communal drawers contained multiple personal toiletry items which required staff to handle them repeatedly, increasing the risk of cross-contamination. In addition, some waste disposal systems, including pedal-operated bins for clinical and contaminated waste, were not functioning correctly. This meant staff were required to lift lids by hand, increasing the risk of infection transmission. Shower curtains and other fixtures also required replacement to maintain appropriate hygiene standards.
These issues indicated that environmental controls were not consistently effective in reducing the risk of infection. Although these concerns were addressed during the inspection, there was limited evidence that they had been identified or acted upon prior to inspection. This reduced assurance that systems were sufficiently proactive in identifying and managing infection prevention and control risks.
 

The provider did not always ensure medicines systems were safe and supported staff to administer medicines consistently.
Medicines were generally administered safely, and records showed medicines were given as prescribed.
However, there were inconsistencies in documentation, particularly relating to ‘when required’ (PRN) medicines. Protocols did not always clearly describe when medicines should be administered or what signs to look for.
For example, PRN protocols sometimes lacked specific instructions for staff, such as clear triggers for use or expected outcomes following administration. This meant staff needed to rely on their own judgement rather than clear written guidance. Audits identified gaps in medicines recording, including instances where documentation was incomplete or inconsistent, without clear evidence of follow-up action
While no evidence of immediate harm was identified, these issues meant medicines systems were not consistently robust. This increased the risk of inconsistent decision-making in relation to ‘when required’ medicines.