Finch Manor Nursing 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 requires improvement. At this assessment the rating has changed to inadequate. Inadequate: This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation. The provider was also in breach of legal regulations relating person‑centred care, safeguarding people from abuse and improper treatment and staffing.

This service scored 28 (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 and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We found repeated safety issues across the service, including unexplained injuries, omissions in care, delays in responding to deteriorating health conditions, and a failure to safeguard people.. A serious safeguarding incident that occurred during the assessment was not disclosed to inspectors, which raised significant concerns about transparency and compliance with their Duty of Candour. Safeguarding notifications were also incomplete or incorrect, limiting opportunities for external oversight.

People’s feedback reflected these issues. Some people reported feeling unsafe or ignored, and inspectors observed instances where people were not supported in a dignified or respectful way. Relatives also raised concerns about how issues were handled, including missing belongings and unresolved themes in care.The findings of the assessment evidenced that complaints and concerns were not used to improve practice or prevent recurrence.

Overall, learning was captured within internal processes, but not embedded or effective. Repeated issues continued, contributing to ongoing unsafe care and persistent breaches of regulation.

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

Systems were not in place to ensure people’s needs were consistently assessed, monitored or escalated. Important risks were missed, and assessments lacked key information, meaning people did not always receive safe or well‑coordinated transitions into the home.

People using the service told us staff did not always check on them or respond promptly, and some said they felt unsafe or unsure who was monitoring their needs. Relatives raised concerns about delays in escalating changes in health and the lack of follow‑up when issues were reported. Staff described difficulties maintaining continuity due to staffing pressures and reliance on agency workers.

Overall, systems and pathways did not support safe care or ensure continuity. Failures to escalate concerns, monitor risk and coordinate with external partners left people at risk of avoidable harm.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

Safeguarding systems were not effective in identifying or preventing harm. Recent safeguarding alerts had identified concerns in relation to, unexplained injuries, delayed medical escalation and failures to act on deterioration of a person’s health. A serious safeguarding incident that occurred during the assessment was not disclosed to inspectors, which raised significant concerns about transparency and their Duty of Candour. Providers must notify CQC of serious incidents or abuse, we found the provider did not always complete notifications correctly. Safeguarding notifications were incorrect or missing detailed information, limiting effective oversight.

People told us they did not always feel safe or listened to, and inspectors observed people left without supervision for long periods. Relatives described repeated safeguarding themes that were not addressed.

Relatives raised concerns about how risks were handled, including repeated issues in care that had been escalated previously. These concerns were not used to improve practice, and safeguarding themes continued to reoccur across the service.

Staff described being busy and struggling to monitor people safely. Agency staff were unfamiliar with people’s needs, which increased the risk of failure to provide safe care and treatment and contributed to inconsistent reporting and escalation.

Overall, safeguarding processes did not protect people from abuse or neglect. Concerns were not recognised, shared or acted on promptly, and repeated failings placed people at ongoing risk of avoidable harm.

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.

We found people were not involved in decisions about managing their risks, and staff did not consistently recognise or respond to changes in people’s needs. Care plans contained omissions and contradictions, and important risks, such as mobility issues, behaviours that challenged, continence needs and deterioration — were not monitored or acted on. People were not given clear information or reassurance to help them understand their risks or maintain as much independence as possible.

People who used the service told us they often waited long periods for help and did not always feel listened to. Some described feeling unsafe or unsure who to speak to, and inspectors observed people left without supervision, support or timely responses. This showed people were not supported to participate in decisions about their own safety or daily routines.

Relatives raised concerns about delays in escalating risks, changes in health not being recognised, and repeated issues that had been reported before. This demonstrated that people and families were not effectively involved in reviewing or managing risks.

Although there was accident, incident and near miss policy in place, the service did not involve people in understanding or managing their risks. Lack of communication, poor record keeping and inconsistent staff practice meant people were not supported to stay safe, maintain independence or make informed choices about their care.

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

Inspectors found environmental and equipment‑related risks across units with some bedrooms presenting risks and not well maintained. We observed, damaged walls and unsafe electrical sockets and found essential equipment was not always used safely or set up correctly. Several airflow mattresses were found unplugged, deflated or incorrectly set for people’s weight, placing them at risk of pressure injuries. Unsafe seating was identified, including a chair unsuitable for a person with frailty and postural needs. Staff were unable to confirm whether referrals had been made, or risk assessments completed. Poor environmental oversight meant these issues were not identified or addressed in a timely way.

Peoples described discomfort and lack of support with equipment for example armchairs and inspectors observed people without working call bells or appropriate equipment to maintain their safety. A person’s radio was extremely loud with no call bell available, and another person had a used urinal left on their table. These findings demonstrated failures to ensure safe, dignified and well‑maintained living environments.

Staff told inspectors they struggled to keep up with cleaning and equipment checks, and this was reflected in the number of environmental hazards observed. Evidence showed that monitoring systems were not effective in identifying poor cleanliness, unsafe equipment or required maintenance.

Overall, the environment and equipment did not support the provision of safe care. Failures to detect hazards, maintain essential equipment and ensure safe, clean environments, placed people at risk of avoidable harm.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

Staffing levels were unsafe across units, and inspectors observed long delays in responding to people who required help. On several occasions, people were left calling out for assistance without support, and call bells took extended periods to be answered. Staff were visibly rushed, overwhelmed and unable to meet people’s basic care needs in a timely and dignified manner.

The significant reliance on agency staff meant people experienced inconsistent care from staff who did not always know their needs, risks or preferences. This contributed to missed care, poor monitoring and delays in escalating concerns to external professionals. Staffing rotas showed that planned numbers of staff were not maintained, especially during key times of the day, and people told us care was dependent on “Who was on shift.”

People’s experiences reflected these pressures. Some people told us they had long waiting times for staff support. Relatives raised concerns about delays in care, lack of oversight and repeated issues that had not been addressed despite feedback.

Staff reported that they struggled to keep up with care demands and had limited time for meaningful engagement, monitoring or record keeping. There was little evidence of effective supervision or development to support staff competence, and poor practice continued without improvement.

Overall, unsafe staffing levels, ineffective deployment and poor oversight meant people did not consistently receive safe, coordinated or person‑centred care.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found mixed standards of infection prevention and control across the service. While some areas were clean and staff understood aspects of safe practice, there were notable inconsistencies which increased the risk of infection transmission.

Inspectors observed unclean equipment, stained bedding and bodily fluids on floors within some bedrooms and corridors. Some rooms had strong, unpleasant odours. Environmental checks and cleaning schedules were not consistently effective in identifying or addressing these issues. Inspectors observed sensor mats, wheelchairs and mattresses required deep cleaning.

People told us that some rooms were clean and well kept, while others reported concerns about odours or hygiene. Inspectors observed that people who were bedbound did not always have tidy or sanitised surroundings, including used continence equipment left on tables.

Relatives raised mixed views; some felt the environment was generally clean, while others reported concerns about the condition of rooms or delays in cleaning following spillages.

Infection prevention and control measures were inconsistent. While there was evidence of some safe practice, the provider did not always identify or respond to infection risks promptly. Improvements were needed to ensure environments, equipment and cleaning processes consistently supported safe care.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found concerns with the management of medicines. As and when required medicines (PRN) ‘PRN’ “when required” protocols were inconsistent. These are medicines that should only be given when a person needs them — for example, for pain, and must be supported by a clear PRN protocol explaining when to give the medicine, how much to give, how to assess whether it is needed, and when to escalate concerns. Some PRN protocols were missing, incorrect or contradictory, meaning staff did not have clear guidance on when or how to administer medicines safely. Some people received covert medicines without evidence of Mental Capacity Act assessments or best‑interest decisions.

Staff did not always understand or use tools such as the Abbey Pain Scale, and inspectors were told some staff were unfamiliar with how to assess non‑verbal pain. Important information, including reasons for administration, dosage, frequency and monitoring was missing from people’s records, increasing the risk of unsafe practice.

People’s medicines were not reviewed promptly, and Inspectors identified referrals to GPs or other specialists were delayed or only completed after inspector intervention for a person. Medication records contained errors, inconsistencies and “copied” information that was not person‑centred.

People told us they did not always understand their medicines or were not asked about their preferences. Relatives also raised concerns about medication errors and communication around changes to medicines.

Overall, medicines were not always managed safely or in a way that protected people from avoidable harm.