Finch Manor Nursing Home

Updated 4 April 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was undertaken by four inspectors, a Specialist Advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Finch Manor Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Finch Manor Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with CQC to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection, there was a manager in post, but they were not registered with CQC.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.

During the inspection

We spoke with the Chief Executive Officer/Nominated Individual, manager, area manager, clinical director, interim manager, 2 unit managers, 2 nurses, 2 senior care staff, 2 care assistants, the chef, and the maintenance officer. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with 4 people who lived in the home and 6 relatives, about their experience of the care provided.

We reviewed a range of records. This included 12 people's care records and multiple medication records. We looked at 4 staff files and a selection of agency profiles in relation to safe recruitment and a variety of records relating to the management of the service.

After the inspection visit.

We continued to seek clarification from the provider to validate evidence. We continued to review evidence in relation to people’s care, and the management of the service. We also liaised with the local authority to share information about the service and our inspection.

Updated 4 April 2024

About the service

Finch Manor Nursing Home provides accommodation for up to 89 people who need help with nursing or personal care. At the time of the inspection 82 people lived in the home. The majority of the people living in the home lived with dementia or other complex health need.

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

The last 5 CQC inspections of the home have continually identified serious concerns with the safety and quality of the service provided for people. There continued to be multiple breaches of the regulations which continued to place people at significant risk of avoidable harm.

People needs were still not adequately assessed or met, with significant gaps and failings in the care they received. Clinical care was ad hoc and poorly delivered which meant risks to people’s health were not always picked up and addressed. Care was not person centred, did not meet their individual needs, or protect their dignity.

Accidents and incident of a similar nature kept repeating. This indicated that the system in place to learn from and prevent injuries, care failures and safeguarding events happening again was not robust. This meant people continued to be exposed to preventable harm.

Medicines were not managed safely. People did not receive the medicines they need to keep them and did not receive them in a safe way to prevent medicines related harm. Diabetes management was poor. Insulin designed to control blood sugars was administered without the relevant checks in place to ensure it was safe to do. This placed people at serious risk of harm.

There was no safety equipment in place to help people clear their airways in the event of a choking episode and not all staff had completed first aid training.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. People’s consent was not sought in line with the principles of the Mental Capacity Act 2005.

Satisfactory pre-employment checks were not always completed when staff were recruited to work in the home. This meant the provider could not be assured they were suitable to work with vulnerable people.

Staffing levels were not safe and did not ensure people’s needs were met. The provider relied heavily on agency staff to staff the service. People told us agency staff did not always know what their needs were or how to support them. One person told us, “My heart sinks if it’s ad hoc agency staff. Some don’t speak English well, so don’t understand my needs and what I’m asking for”. Everyone we spoke with said that there were not enough staff on duty. Some people said they waited a long time for staff to come when they pressed their call bell for help.

Systems in place to monitor the quality and safety of the service were not effective and did not ensure risks to people’s health, safety and welfare were identified and managed. Managerial and clinical oversight by the provider and registered persons was not thorough and risks to people remained.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 17 August 2023).

At this inspection, we found that the quality and safety of the service continued to be inadequate. Multiple breaches of the regulations were found, resulting in a continued rating of inadequate. At this inspection, breaches of regulations 9 (Person centred care); 11 (Need for Consent); 12 (Safe care and treatment); 17 (Good governance); 18 (Staffing) and 19 (Fit and proper persons) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found.

The overall rating for the service has remained inadequate. This is based on the findings at this inspection.

Why we inspected

This inspection was prompted by the inadequate rating given at the last inspection. We also had concerns about a number of safeguarding incidents reported to us by both the provider and the Local Authority which raised concerns about the safety of people’s care and the management of the service. As a result, we undertook a comprehensive inspection of the service.

Enforcement

We have identified breaches in relation to the safety of people’s care, assessment and risk management, accident and incidents, the management of medicines, the implementation of the Mental Capacity Act 2005, staffing levels, staff recruitment, staff training, staff supervision, the delivery of person centred, responsive care and the overall governance of the service.

Immediately after the inspection, we asked the provider to submit an urgent and immediate action plan for improvement. The local authority were also informed about our concerns to ensure people were safeguarded from potential harm.

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 work alongside the provider and Local Authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

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 of their 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.