Finch Manor Nursing Home

On this page

• 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 requires improvement. At this assessment the rating has changed to inadequate.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 people’s safe care and treatment.

This service scored 25 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Assessments were not robust, accurate or regularly reviewed. Pre‑admission assessments lacked key information regarding skin integrity and behaviours that may challenge, and people arrived at the service without clear plans in place to manage known risks. Once living in the home, people’s needs were not consistently reassessed when their condition changed for example a person who displayed increasing episodes of distress or challenging behaviours had not been reviewed since admission. Care plans contained significant omissions and contradictions, for example a person’s care plan reflected inconsistent information regarding capacity and a diagnosis of dementia

Inspectors found examples where people’s needs were not identified or monitored, including concerns relating to skin integrity, continence, mobility, pain and mental health. Inspectors found gaps in referrals to health professionals, such as mental health teams, GPs and podiatry, and only made after inspectors raised concerns, meaning opportunities to prevent deterioration were missed.

People who used the service and their relatives described long periods without engagement or monitoring, and some said they felt unsafe or ignored. These experiences reflected the lack of meaningful assessment and review. The provider did not ensure people’s needs were accurately assessed or used to guide effective care. This placed people at ongoing risk of receiving care that did not meet their needs or promote positive outcomes.

The provider did not ensure people’s needs were accurately assessed, regularly reviewed or used to guide effective care. This placed people at ongoing risk of receiving care that did not meet their needs or promote good outcomes.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Inspectors found care plans and assessments did not reflect best practice for managing pressure care, continence, nutrition, mobility, mental health or behaviours that challenge.

Risk assessments were incomplete or incorrect, and essential tools — such as Waterlow scores, mental capacity assessments, skin integrity plans and behaviour monitoring, were either missing, contradictory, or not updated when people’s needs changed. This meant staff did not have accurate information to follow evidence‑based approaches.

Staff did not consistently follow evidence‑based guidance when supporting people with distressed behaviours, pain management or personal care. For example, ABC charts were completed for repeated episodes of distressed behaviour, yet no analysis or review took place to inform a behaviour support plan or update care strategies. Pain assessment tools, such as the Abbey Pain Scale, were not understood or used effectively by staff, resulting in inconsistent pain management.

People’s postural, mobility and continence needs were not assessed or reviewed when changes occurred. Unsafe seating and unsuitable equipment were left unaddressed, and care planning failed to incorporate approaches for reducing falls, maintaining skin integrity or promoting independence. For example, a person who required assessment for a new wheelchair due to risk of falls and another person using the service who required assessment for a reclining chair due to risk of falls from their current chair.

People and their relatives described inconsistent or poor‑quality care, with people often left without meaningful engagement, supervision or support that aligned with their assessed needs. Some reported that staff did not understand their routines or preferences, which reflected the lack of evidence‑based planning and review.

Overall, the provider did not deliver care in line with evidence‑based practice, which resulted in unsafe, reactive and inconsistent support.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

Staff and teams did not work together in a way that ensured people’s needs were consistently understood, communicated or reviewed. Although governance processes were in place, including regular audits, these systems did not lead to improvements in staff practice or better outcomes for people.

Feedback from professionals highlighted variation in communication and practice across units. External partners reported inconsistent escalation, missed signs of deterioration and delays in involving professionals when people’s needs changed. Safeguarding investigations also demonstrated repeated failures in communication between teams and external professionals.

Staff feedback was mixed. While some staff described good working relationships, others highlighted language barriers, frequent staff changes and inconsistent supervision. Staff confirmed call bell responses were inconsistent and said they sometimes checked on people themselves when delays occurred, demonstrating gaps in coordination.

Relatives reported inconsistent communication when health needs changed and described care as dependent on which staff were on duty. One relative told us, “Some staff need more training… it’s not right,” while another said the home was “Hit and miss” and depended on which staff were on duty. Concerns about missed support, incomplete information and lack of follow up reflected poor coordination across units and shifts.

Overall, limited communication, unclear escalation processes and inconsistent teamwork contributed to fragmented care and avoidable risks.

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.

The provider did not make sure people were supported to live healthier lives or maintain their health and wellbeing. People’s changing needs were not consistently recognised, monitored or responded to, and support to promote healthy living was inconsistent or absent.

Inspectors found multiple examples where people’s physical and mental health needs were not identified or acted on. People with deteriorating conditions, behaviours that challenged,swallowing risks, reduced mobility, pressure‑related concerns and nutritional needs were not consistently assessed or monitored. Referrals to health professionals, including mental health teams, GPs, podiatry, dietitians and seating specialists, were delayed or only made after inspectors intervened.

People were not supported to maintain healthy routines or prevent further decline. Whilst staff and activity staff had good rapport with people and some activities were taking place, several people were observed inactive for long periods without stimulation or encouragement to move, engage or participate in daily life. Individuals who were bedbound did not always receive regular checks, repositioning or support to maintain comfort and well‑being.

Relatives expressed concerns about how well people’s health was monitored, including delays in recognising deterioration, managing long term conditions and responding to changes in mood, mobility or appetite.

Overall, people were not supported to live healthier lives. Limited monitoring, inconsistent escalation and lack of person-centred support contributed to avoidable decline and poor outcomes.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive, consistent or monitored, or how they met clinical expectations and the expectations of people, and what mattered to them.

Monitoring systems were ineffective. Inspectors found gaps in observations and records for example, pain assessments, and behavioural monitoring. Daily records often contained omissions or inaccuracies, where there was a change in people’s needs this was not consistently reviewed or escalated.

People did not experience improved outcomes because monitoring information was not used to inform staff practice. Some people who used the service described poor engagement and said they waited long periods before staff noticed they required help

Relatives raised concerns that changes in health were not identified early, describing worsening symptoms, reduced mobility and missed opportunities for clinical review. Staff described pressures that impacted their ability to observe and monitor people consistently.

Overall, the provider did not monitor people’s needs effectively or use information to improve outcomes. Failures to identify deterioration, review risks and act on concerns placed people at risk of avoidable harm.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. Inspectors found multiple breaches of the Mental Capacity Act (MCA), the legal framework that protects people who may lack capacity to make specific decisions and requires staff to act in their best interests.

People who lacked capacity did not always have mental capacity assessments completed for specific decisions, and where assessments were completed, they were not always accurate or supported by best‑interest discussions. For example, a person using the service who had no family or legal representative was assessed as lacking capacity for personal care. Despite this, no advocate had been requested to support the person to participate in decisions about their care or have someone to represent their views in the decision‑making process.

A Deprivation of Liberty Safeguard (DoLS) authorisation is a legal safeguard under the MCA for people deprived of their liberty to receive care. DoLS processes were not followed. A person who repeatedly expressed a wish to leave the service was deprived of their liberty without a lawful authorisation because an urgent DoLS application had not been submitted. This was only actioned after inspectors highlighted the issue, indicating a failure to safeguard the person’s rights.

Consent was not consistently obtained in daily care. Observations completed by the inspection team observed a person having a clothing protector placed around their neck at mealtime without any explanation or request for consent, which caused visible distress. Other people who used the service told us staff often carried out tasks without informing them or involving them in decisions about their support.

Medicines were not always administered in line with MCA requirements. Covert medication was used for some people without any mental capacity assessment, best‑interest decision or documented agreement from relevant professionals. This meant medication was given in a way that did not protect people’s legal rights or ensure their involvement.

Overall, staff were trained in MCA training, however people were not consistently supported to give consent, and the provider did not follow the Mental Capacity Act to ensure decisions were lawful, person‑centred and in the individual’s best interests. This placed people at risk of receiving care and treatment that did not respect their rights or wishes.