Fir Trees House

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 remained.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

We identified a breach of the legal regulations relating to person centred care. People were not encouraged to build their independence or integrate into their local community.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Pre assessments were carried out prior to a person moving into the service. These were done to consider if the service could meet the physical and emotional needs of a person.

However, we identified one person for whom their mobility and psychological needs were not being met because of the environment. They told us, “I can’t get up and down the stairs easily, so I can’t get to the door.” They went on to recall their first day at the service, saying, “Staff laughed at me as I tried to get up the stairs, I felt very unwell. I had to rest on the stairs, I thought I was going to lose consciousness, my head was spinning and they were laughing.” They confirmed how they hardly left their room now and when they do it was solely to use the toilet and bathroom on that floor. This left the person at risk of isolation and their wellbeing needs not being met due to environmental factors. There was no evidence the staff had considered other ways to support the person to mobilise downstairs or considered how to engage with the person in their room to make them less isolated.

The registered manager told us, “We allocate keyworkers depending on people’s needs and staff skills, and let people take the lead. We tailor activities to the individual and not everyone wants to play board games.” However, we only observed 1 person leave their room and be supported with any activities during our assessment.

Staff supported some people to access services such as the dentist and optician. However, 1 person’s care records stated, “[Person] refuses to see the dentist” and “[Person] refuses to see the optician.” There were no risk assessments to evaluate and mitigate these risks and there were no plans in place to support a desensitisation or encouragement programme for the person to be able to access these in the future

People’s records contained an assessment of their needs undertaken before they moved into the service, as well as assessment documents from other agencies with information, such as the local authority or hospital.

However, the provider did not always ensure that regular reviews effectively assessed outcomes for people. The ‘outcomes’ sections within the support plans of 1 person were identical from year to year, with no plans in place to support the person to meet them and no evidence any of them had been achieved. Monthly staff meeting minutes did not assess and discuss how the staff could change the support they provided to better support people to achieve outcomes.

One person was able to undertake activities independently without staff support, and did so, but people who needed more encouragement and motivation to leave their rooms were not always supported with this. These people did not receive the support that was described in their care plan. Each person’s care plan described them undertaking various activities outside the home, and tasks around the house to promote independent living skills. However, we did not see evidence that these were done consistently.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. Support provided to people was not evidence-based or in line with current good practice.

The support staff provided to people was task-focused and did not enhance their quality of life. The support staff provided to people did not meet the requirements of Right Support, Right Care, Right Culture guidance. The behaviours of staff did not support people to lead confident and inclusive lives, and care was not person centred.

People’s care plans stated they should be encouraged to prepare their meals and cook with a member of staff. The activity board in the service stated this was happening three times a week. However, all 3 people we spoke with stated staff made their food and brought it to their rooms for them. One person told us, “[Staff member] asked me what I would like for lunch today. She has never asked me before. Is that because you (CQC) are here, today?” This demonstrated people were not receiving the support required to enhance or maintain their skills on independent living.

Staff also confirmed that people were not involved in preparing their meals. One staff member told us, “Sometimes it’s very busy, assisting people with personal care and preparing their food. Sometimes everyone wants something different [meals] so that’s very busy.”

Systems and processes weren’t in place to ensure evidence-based care was delivered. One person’s review by their key worker in November 2023 recorded that they needed to be encouraged to be more independent in daily activities such as cooking and laundry. However, we saw no evidence that this had been focused on or encouraged in records or through observation.

People with medical conditions requiring a special diet were not provided with meals that met their dietary requirements. This had led to a deterioration in their health and the use of insulin injections now being considered by health care professionals.

Staff supported people to all health appointments, and these were clearly recorded with actions for the staff. People had been referred to some medical professionals when needed and facilitated access to these, such as the GP, diabetic nurse and district nurse. Staff described a recent example when a person was vomiting for several days, and they pushed for a referral to a medical specialist for tests.

Staff felt there was a good level of communication amongst them. One staff member told us, “We work together well. Handovers are fluent and verbal.” The deputy manager also confirmed staff worked well together as a team.

Any follow up actions from people’s medical and health appointments were recorded in care plans for to allow staff to follow the new guidance. One staff member confirmed, “No one needs any Speech and Language team guidance as no one is at choking risk.”

We did not receive any feedback from partners for the evidence category in the quality statement.

People had clear health action plans and hospital passports that detailed their medical needs as well as their communication needs and any reasonable adjustments required to ensure a better experience in hospital should they need to attend or be admitted. Staff supported each person to attend an annual health check with their GP as well as an annual medicines review.

Staff did not always support people to live healthier lifestyles. Although some people had activity planners in their records and there was a pictorial activity planner pinned to the noticeboard in the dining area, we did not see people undertaking any of the activities listed, nor were these recorded in their support records. There were also no references to activities detailed in people’s monthly keyworker meeting records.

3 of the 4 people we spoke with told us they did not take part in any activities. One person was able to undertake activities independently without staff support, and did so, but people who needed more encouragement and motivation to leave their rooms were not always supported with this, and therefore did not receive the support that was described in their care plan. Each person’s care plan described them undertaking various activities outside the home, and tasks around the house to promote independent living skills. However, there was no evidence that these were done consistently.

Staff told us that people were difficult to engage in activities and motivate to undertake household tasks. One staff member told us, “To get people out you have to gauge their mood, but some people want to stay indoors.” However, we observed staff not taking opportunities throughout the day to build engaging and trusting rapports with people which would have motivated people further to undertake chores together, as well as improve their mental wellbeing. Instead, staff sat for 90 minutes without any attempts to engage with people.

The management team told us that staff would create a weekly meal plan with people. However, when checking the refrigerator and freezer we identified the ingredients needed to make these meals were not available. Instead, there was a large amount of jarred sauces and microwave meals. These were high in sugar, fat and salt.

Staff did not encourage or motivate people to undertake exercise or eat healthier foods. For example, 1 person had access to unhealthy foods that were in contradiction to the specialist diet required to manage their diabetes. There was also an ‘Eatwell’ guide on the notice board in the dining area, however as people did not always use this space and chose to eat in their rooms, its effectiveness as a guide was limited.

The provider’s activity schedule was sparse and did not include person centred options. For example, the evening activity for 4 of the 7 days of the week was to watch a TV gameshow. There was no evidence discussions had been had with people to establish this is what they were interested in, and we did not identify that this ‘activity’ was going ahead as people did not leave their rooms.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

People did not always receive good experiences in relation to their consent to care. One person complained that the staff often just knock and walk in, so she had taken to choosing carefully when getting dressed and undressed. They informed us of a recent event when a member of staff knocked and then walked straight in to announce a doctor was there to see her. The male doctor had followed the staff member in, turned round and walked straight out again. The person was pleased about the doctor’s response to the situation, but cross with the staff member for allowing that to happen. There was no evidence there had been an apology, or that the situation had been discussed in staff meetings or key worker meetings with people to address the issue and provide a resolution.

Other people we spoke to told us staff did not enter their room without knocking first.

The staff and registered manager did not always demonstrate a good understanding of consent, capacity and making decisions. Instead, the fallacy of choice was used as an excuse not to provide positive, proactive support. When we asked the registered manager about staff buying unhealthy foods for the person with type 2 diabetes, he told us, “She has capacity, it’s her independent choice. We have to respect that” without awareness of the impact of facilitating such access to unhealthy foods. A further staff member said, “People choose to eat their meals in their rooms rather in the dining area, I bring it to them.”

However, other staff member’s knowledge and understanding of mental capacity seemed to be of a higher level. One staff member said, “Mental capacity? It’s huge. They can have capacity to choose what meal to make but not about a GP visit. If they can’t make a decision, then do a best interest decision for the service user and not the staff.”

People had access to advocates, which were arranged by their care coordinators and social workers. People’s records contained a number of assessments of people’s capacity to understand and make decisions. Each person had a Deprivation of Liberty Safeguard (DoLS) in place. DoLS are legal safeguards to protect patients who lack capacity and are deprived of their liberty in hospitals or care homes.