Firs Hall Care Home Limited

Updated 11 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Firs Hall Care Home Limited is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Firs Hall Care Home Limited is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection the acting manager had applied to be registered with CQC.

Notice of inspection

We gave the service 24 hours’ notice of the inspection to assess any COVID-19 risks.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with three people who used the service about their experience of the care provided. We spoke with five members of staff including the acting manager, a team leader, a care assistant, the activities coordinator and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included four people's care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 11 May 2022

About the service

Firs Hall is a residential care home providing personal care to up to 31 people. At the time of the inspection 20 people were living at the service. The accommodation is provided in one building with bedrooms across two floors and communal areas on the ground floor.

People’s experience of using this service and what we found

At the previous inspection we made a recommendation that the provider should review their medicine recording processes and their financial auditing systems. At this inspection we found improvements had been made in these areas.

The service had systems in place to help safeguard people from the risk of abuse. All risks were monitored and managed well. Health and safety measures were in place and required certificates were up to date. Medicines were managed safely at the home. All required infection control measures were in place. Staff had completed infection prevention training and were aware of all current guidance around COVID-19.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff were recruited safely and there were sufficient staff to meet the needs of people using the service. Staff were positive about the support they received from the management of the service.

There was an open and honest culture at the home and notifications were made to CQC as required. People were as involved as they were able to be with their care and support. There was an on-going improvement plan, which included addressing environmental repairs and upgrades. Partner agencies reported good working relationships with the provider and new manager.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 14 July 2021). At our last inspection we recommended that the provider review their medicine recording processes and their financial auditing systems. At this inspection we found the provider had acted on the recommendation and improvements had been made in these areas.

Why we inspected

We undertook this targeted inspection to check the provider had followed their action plan. This report only covers our findings in relation to the key questions Safe and Well-led. For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating. The overall rating for the service has remained good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Firs Hall Care Home Limited on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.