Fir Trees House

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 as 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.

This service scored 53 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

One person was in the process of moving to another service. This was initiated following a Court of Protection hearing which detailed how this person was not receiving the support they need for a good quality of life. Another person was moved from the service in July 2024 after a significant deterioration in their mental health. There was no evidence to demonstrate any investigation had taken place to determine where the service could improve and that lessons were learnt.

Opportunities were missed to encourage a learning culture with staff. We observed staff meeting minutes from March and April 2025 were identical. This demonstrated the management team had not sought to identify areas for improvement or discussed best practice with staff to build upon their existing knowledge.

The registered manager was not open and transparent about incidents that had occurred in the service. They told us, “All the social workers, advocates, care coordinators, GP and other professionals who visit these [people] all the time have no concerns about their nutritional needs, wellbeing or engagement. Everyone is so pleased and impressed at the quality of service provided and how each of them is being looked after.” However, the concerns from the Court of Protection and Environmental Health team demonstrated otherwise.

Despite this, both staff members said they felt they could raise issues and be listened to at work. One staff member told us, “The managers listen to me, they respond almost immediately.” Another said, “I feel able to raise issues and be listened to.”

Lessons were not always learnt to improve people’s health and wellbeing. For example, we identified one person’s care review in November 2023 had identified they required a prescription of continence pads from the local continence service. However, their daily continence records demonstrated these were not being used and staff had not recorded the reasons why. Their social worker identified a malodour to the area around the person’s room during their review. 2This had been reported to staff however, no improvements had been made as we identified the same malodour during our assessment. This meant the person had been placed at risk of negative outcomes such as moisture sores

There was little consideration to ensuring smooth transitions between services when people moved into or out of the service. There was no transition plan in place for a person due to be moving out of the service shortly after our assessment. One person who had moved into the service after being an inpatient in a mental health ward for 27 years did not have a transition plan despite the likely adjustment required.

The registered manager was dismissive of the need for a transition plan for people. They told us, “In effect, transition plans are being put together by social workers and care coordinators in situations where it is necessary. Other than that, visits by prospective residents and their families are facilitated by care coordinators, discharge coordinator etc.” This demonstrated that the registered manager did not understand their role in ensuring that people who moved into and out of the service had support from the service for such a major life change as moving home.

Following our assessment, the registered manager sent us a copy of a transition plan for the person who had moved into the service from a long stay at a mental health ward. However, it was undated and referenced events that happened in the person’s life after they had moved into the service. Therefore, it was ineffective in its use as it was created retrospectively.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

One person’s monthly keyworker meeting records noted that they felt safe. Another person told us, “It is a safe place.” A relative told us they felt their family member was safe at the service. They told us, [Deputy manager] is very attentive to [person], and spends a lot of time with him.”

However, a recent environmental health assessment had identified people were not safe due to a poor standard of hygiene around the premises. The registered manager had been dismissive of the concerns and labelled them ‘malicious’, rather than openly accepting feedback to ensure people were safeguarded. This left people at risk of receiving ongoing unsafe care due to a defensive rather than a collaborative approach.

Not all staff who worked in the service had signed to say they had read and understood the safeguarding policy and procedure.

Staff members told us they would report safeguarding concerns to the registered manager. Neither was able to tell us the other agencies to which they could report such as the local authority or Care Quality Commission (CQC).

The registered manager said there was “always learning from every safeguarding. We have a report and a staff debrief, then take action on the lessons learned.” However, he was not able to show evidence of this as the last safeguarding recorded was January 2022. Therefore, we could not be assured safeguarding concerns were being reported appropriately, due to the concerns we identified from the Court of Protection during our assessment.

People had appropriate mental capacity assessments in place to determine if they lacked capacity to make key decisions about their care, such as around their medicines or finances. Deprivation of liberty safeguards (DoLS) were in place. These allow lawful restrictions to be put in place in order to keep someone who lacks mental capacity safe.

The provider did not always work with people to understand and manage risks.

One person’s care plan confirmed they had a diagnosis of type 2 diabetes. However, there was no diabetes risk assessment in place to provide appropriate guidance to staff should the person have a diabetic emergency. We informed the registered manager of this, who confirmed and sent us evidence that a risk assessment had been put in place following our assessment. However, upon reviewing this document we identified it was for a person at one of the provider’s other services. Therefore, it did not provide personalised information in relation to the person at Fir Trees House and how to support them specifically with their diabetes.

However, one person told us staff had supported them to stop their addiction and because of this they had “been well for a long time.”

The management team explained the person with diabetes had mental capacity and said they had to encourage them to eat less sugary things. The person's care plan stated, “Staff to encourage and support [person] and help her to learn the skills to follow a healthy lifestyle and maintain a balanced healthy diet. This includes planning her weekly menu with her and supporting her to follow it” and “Staff to encourage [person] to reduce the amount of sugary treats and drinks she takes and to encourage [person] to choose sugar free alternatives and diabetic sweets”. When we asked staff how they supported the person with this, one member of staff told us, "We make sure she doesn’t have sugar in her tea or coffee otherwise not much." However, the person did not take sugar in her hot drinks. The person was not involved in cooking their meals. Therefore, there was no evidence that staff were following the person’s care plan in relation to encouraging and supporting her to learn skills around a healthy lifestyle.

Not enough was being done to support the person to make healthy decisions in relating to their diet. We observed the refrigerator and cupboards were full of sugary snacks. Furthermore, there were no fresh ingredients to make sauces or meals from scratch. These were instead either from a tin or microwave meals.

Systems and processes had not identified the issues around the person’s diabetes and nutrition. The deputy manager told us, “[People] don’t have any major health concerns and none of their conditions are worsening.” However, the nutritional concerns around the person’s diabetes were having a detrimental impact on their health. In their most recent GP and diabetic nurse appointment records noted they would have to go on insulin shortly if their diet did not improve.

Although people living on the ground floor felt the environment met their needs, one person living on the first floor had experienced concerns with her environment. They told us they were very surprised when they arrived to find that their room was on the first floor. “They wouldn’t take me back to the other place because it had closed, so I had no choice to manage the stairs.” Despite the person living at the service for several months, the management team had only recently decided to install a stair lift at the service. This would not benefit the person as they were in the process of moving out of the service.

The registered manager told us the reason for the recent decision to install a stair lift was due to “most of the referrals we have received recently were for people with mobility needs”. The management team explained this limited their ability to accommodate people in the upper floor bedrooms. Therefore, this was not in reaction to trying to meet the needs of the current person living on the first floor with mobility issues.

There was a large garden with raised planter beds. The deputy manager told us they tried to involve people living at the service with tending to these. They said, “I love gardening in the summer, sometimes [two people] come out to watch.” However, there was no evidence that people were directly involved in the gardening.

There was a designated outdoor smoking area for people to use, and each person had an environmental risk assessment. The premises was undergoing a refurbishment at the time of our assessment. There was new flooring installed on the ground floor, and a new kitchen, wet room bathroom, fire doors, and tiling and painting all of the walls was planned.

Fire extinguishers had been checked to ensure they were safe to use in the event of an emergency. However, there had been no plans to refurbish the service until the environmental health team voiced their concerns about the hygiene and cleanliness of the service. Therefore, systems and processes were not always effective in ensuring the environment was safe for the people using it.

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

Personal emergency evacuation plans (PEEPs) were in place to record what support people would require to leave the service in the event of an emergency such as a fire. However, from these we identified there was not enough staff at night to support people should they need to evacuate the premises. One person required the support of two staff to evacuate. However, there was only one waking night staff member between 8 p.m. and 8 a.m.

There was no systematic approach to determining the number of staff for each shift, such as a dependency tool. The deputy manager told us, “I spend an hour a day with the residents, particularly [one person] as he has no outside activities” and “We always work very flexibly as a team. We don’t need a dependency tool with so few residents, we will get more staff when we get more residents.”

The registered manager added, “Every resident has agreed funded hours to which the service is accordingly and appropriately staffed. Dependency tool is just a terminology.” This demonstrated a lack of understanding, as it is still a provider's responsibility to install a system that ensures suitable numbers of staff are at the service to meet people's needs throughout the whole day, not just during funded hours from the local authority.

Staff were task-oriented and did not spend time with people outside of meeting their care needs. On the afternoon of our visit 2 staff members sat in the hallway for 90 minutes rather than trying to engage with the people living at the service. Despite people at the service having an enduring mental health diagnosis or being assessed for autism, neither staff member on the day of our visit had any previous experience working with autistic people or people with enduring and significant mental ill-health. This could leave people at risk of not receiving care from staff members who had the knowledge required to meet their needs.

The provider’s staffing rota demonstrated that at least 2 staff members should be on shift between the hours of 8am to 8pm. However, when we arrived at the service at on the second day of our assessment at 6.30pm, the deputy manager had left their shift early. Another staff member confirmed the deputy manager had left at 6pm. This left the service at an unsafe staffing level.

The provider had their own training team. One staff member told us, “I have had training in safeguarding, care planning, food hygiene, infection control, all the mandatory training.” Another staff member told us how the company was supporting her to complete a qualification in healthcare. Supervision meetings were recorded monthly. One staff member told us, “I have supervision occasionally. We talk about training and the [people].” There was no agency staff used and any gaps in the rota were covered by staff from the provider’s other service.

People told us the service was not kept hygienic and clean. One person told us, “They don’t clean, I have never seen them clean. I don’t hear the hoover going.” The recent environmental health assessment had identified that the service was dirty and unhygienic, including a worn kitchen, thick grease and dirt on surfaces, and an unclean cooker.

Staff told us they had training in infection control, and we saw records confirming this.

During the first day of our assessment, the home was in need of refurbishment. We identified the floors in people’s rooms were unclean, with remnants of food and dirt on them. A discarded lump of hair was observed on a hallway radiator. The hair was thick with dust, demonstrating it had been there for some time. Some surfaces with sticky, such as the stairway banister. On the second day of our assessment, we observed the refurbishment was underway and some areas of hygiene in the service had improved.

Personal protective equipment (PPE) was available for staff to use.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People’s medicines were managed safely. The medicine administration records (MARs) we checked were accurate and up to date. People’s medicines records contained information about any medicines to which they were allergic, and guidance was in place for any medicines prescribed 'as and when required' (PRN). There were no people receiving their medicines covertly at the time of our assessment.

Staff responsible for administering medicines told us they had received training in medicines management and their competency had been assessed.

There were appropriate procedures in place for the ordering, storage, administration and disposal of medicines. We saw evidence that indicated medicines were audited monthly to identify any concerns and address shortfalls.