Faith House Residential Home

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• 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 (November 2022). At this assessment the rating remains requires improvement. This meant some aspects of the service were not always safe.

The service was in breach of legal regulations in relation to safe care and treatment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were some processes to monitor, identify, record and learn from incidents. Accidents and incidents which had occurred in the service were recorded and follow up action was taken. Staff told us learning from incidents was discussed during staff meetings. However, we found learning was not well documented in records of staff meeting minutes and complaints we reviewed.

Where people had fallen or had frequent falls, the GP was notified, and appropriate referrals were made. The staff told us they looked for trends to prevent re-occurrence.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns appropriately. There were safeguarding procedures to help keep people safe. Records showed the provider had taken the appropriate action and referred any safeguarding concerns to the local authority and CQC as required.

Staff had received training in relation to safeguarding people from abuse. They demonstrated a good understanding of safeguarding principles and procedures. They told us they would report any concerns to the registered manager and the local authority.

Where people were being deprived of their liberty, appropriate referrals had been made to the local authority to ensure this was done lawfully and in the least restrictive way.

There were systems to identify, assess and manage risks to people. However, these were not always completed in full. Most individual risks to people had been identified and assessed. People’s care plans contained person-centred details. For example, in relation to the management of diabetes. However, since November 2023, people’s care plans and risk assessments were in the process of being transferred from paper records to an electronic care planning system. We found some individual risk assessments had not been transferred to the electronic system, and not all risks had been reviewed and updated. For example, for 1 person in relation to epilepsy and choking risks. This meant we could not be assured the information was up to date and fully accessible to staff.

The provider told us how they encouraged people to take positive risks and promoted independence. The staff team had worked with 1 person to develop a risk management plan. The person had a health condition which presented some risks; however, they were keen to walk to the local shop alone. A plan was developed with the person, staff and their family which included assessing risks such as road safety. The provider told us the person gained independence and autonomy which had a positive impact on their wellbeing.

The provider had systems to detect and control potential risks in the care environment. However, we identified some environmental risks which had not been sufficiently assessed and addressed in a timely way.

For example, during our site visit we raised concerns about the accessibility of locked fire exits within the service. We found not all actions had been completed following an inspection from the fire authority in July 2024. Timely action had not been taken to update the fire risk assessment for the premises. Other risk assessments contained inconsistent information about which fire exits were in use and where keys for fire exits were kept. We found not all radiators were covered in line with the premises risk assessment to manage the risk of burns to people.

During the assessment the provider took prompt action to improve procedures for staff holding keys to fire exits, the kitchen fire exit was taken out of use and a new fire risk assessment was completed. We notified the fire authority who visited the service, they told us they were satisfied with the measures in place. The other records we reviewed in relation to the premises were satisfactory.

There was a programme of ongoing maintenance, refurbishment and decoration with several improvements noted since the last inspection. The kitchen had been renovated, to create a more comfortable communal space. Other refurbishment work included the redecoration of corridor and landing areas to include dementia friendly themes. This included the use of brighter colours, images and items that were reminiscent for people. The provider was proud of the work undertaken. Checks were undertaken of the safety of the premises equipment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.At the last inspection we could not be satisfied the systems and processes ensured safe levels of staffing. We identified risks with staffing levels during the night, with only 1 staff member working and 1 on call. At this inspection we found improvements had been made with increased staffing levels.

The provider told us, and records confirmed, staffing levels during the night had been increased to 2 staff. This helped to ensure people were able to receive safe and person-centred care. One member of the management team lived nearby was on call. One person who lived at the service required several hours of 1 to 1 care during the day. A staff member was allocated to support the person.

The provider told us they had recruited new staff since the last inspection. They were proud of the work undertaken to recruit and maintain the current staffing levels.

The staff told us, they felt there was enough staff to provide safe and effective care. The provider told us the service had a core team of permanent staff, who helped each other to cover periods of staff sickness and annual leave.

Training records confirmed staff had regular training in several areas. This included, medicines, safeguarding, moving and handling, end of life care, supporting specific behaviours, catheter care and dementia care. The provider told us all training was refreshed annually. The staff confirmed they felt supported by the management team, received a comprehensive induction when they started in post and had regular supervision and appraisals.

Recruitment processes were satisfactory, and relevant checks were carried out before new staff started working at the service. We spoke to the provider about ensuring a full employment history was always recorded for new staff, as some staff files did not contain comprehensive records.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Medicines were not always managed or administered safely in line with national guidance. Some people had been prescribed PRN 'as required' medicines. However, the provider confirmed there were no written protocols to guide staff as to how and when to administer these medicines.

The staff administered topical creams; however, we found there was no clear guidance, including body maps, to show staff where the cream should be applied and the quantity required. The manager told us topical medication administration records (MARs) previously used, which included body maps, had been taken out of use.

We identified not all handwritten entries on MARs had been checked by another member of staff to ensure transcribing had been completed accurately.

Medicines were administered covertly to 2 people. Covert medication is the term used when medicines are administered in adisguised format, for example in food or in a drink, without the knowledge or consent of the person receiving them. However, we found not all necessary procedures had been followed in line with national guidance and the provider’s policy.

We found arrangements to covertly administer people’s medicines had not been regularly reviewed. The documentation was not specific to each medicine. Appropriate professional guidance had not been consistently obtained as to how each medicine should be covertly administered, including which foods or drink each medicine can be mixed with safely. This meant we could not be assured the arrangements continued to be in people’s best interests and staff had all the information they needed to administer these medicines safely.

Medicines were stored securely. We checked medicines administration records for some people and found their medicines matched the stock levels recorded. Staff confirmed if they administered medicines at the service, they had completed medicines training, and their competency had been assessed.

During the assessment the provider responded promptly to the shortfalls identified. They provided evidence of updated records and contacted health professionals for further guidance and support on administering medicines covertly.