The Firs 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. At this assessment the rating has remained 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.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed.

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.

The registered manager demonstrated a good understanding of learning from accidents and incidents and understood their responsibilities under the duty of candour. Incident forms were completed by staff and reviewed by the registered manager. We reviewed 4 incidents, and the actions staff had taken to maintain people’s safety. For example, updating fall risk assessments. In addition to this, we also found the registered manager used a tool to monitor accidents and incidents for any themes or patterns.

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 registered manager told us how they ensured safeguarding incidents were fully investigated and referred to relevant agencies. Staff had received training in how to safeguard people from abuse and understood how to report any concerns. People and their relatives told us they felt the service was safe. One person told us, “I am safe here, the staff are very good.” And a relative told us, “[Person] is well cared for, staff are friendly and caring.” We found safeguarding information was displayed on information boards throughout the service which aided everyone’s awareness of what to do if they had any concerns, however we found consent had not been obtained for the use of stair gates. We found there was no evidence to determine if people had the mental capacity to consent to the use of this restriction to protect their health and safety, or if the consideration of DoLS (Deprivation of Liberty Safeguards) authorisations was required. We raised this with the registered manager who told us of the actions they would take to put this right.

The provider worked with people and their relatives to understand and manage risks. Relatives provided positive feedback on how their family members were supported. One relative told us, “They care for [person’s] physical and emotional needs, staff always tell me how [person] has been.” And another relative told us, “Staff know all the little things about [person], they pick up on things quickly and get help, they always let me know.”

Risk assessments had been fully completed to manage people’s individual risk and care was planned to mitigate or reduce these risks, clearly identifying people’s preferences. It was evident, referrals were made to specialised services to meet people’s needs, for example, district nurses for catheter care.

Staff monitored and recorded people’s weight from the point of moving to the service and on a monthly basis thereafter. We reviewed 5 people's weight charts and found no significant weight loss or gain.

Respect forms had been fully completed and involved the person and family. They were stored within the electronic case record and paper-based records were also available so that staff could access them quickly if required.

Within the electronic care records warnings about people’s care were flagged. For example, constipation, or falls. This alerted staff to risk issues and was linked to risk assessments and care plans for staff to mitigate risk. For example, a person was known to suffer with constipation, and they had support for a community matron. Individual risks in relation to people physical health was also linked to the GP record. Staff could view each person’s GP record and see what action the GP had taken to support people.

The provider had not always acted in a timely manner to address known health and safety risks. We found the service had a legionella risk assessment completed in January 2024 which outlined actions that should be taken within 30 days, we found these actions had not been completed until February 2025.

We also identified hazards in the service during our visit which had not been thoroughly risk assessed, we raised this with the registered manager who took immediate action to ensure people’s safety.

We found areas of the service had not been well maintained such as the bathrooms, carpets and the flooring in a person’s bedroom. The provider had a refurbishment plan in place, however this work had not yet commenced at the time of our assessment and action had not been taken to assess or mitigate these issues prior to the refurbishment starting.

The registered manager had a dependency tool in place which they used to inform staffing levels, we reviewed this and found this corresponded with the staffing rotas. Relatives told us they felt staffing levels were reduced at weekends and this meant that people did not have the same opportunities as they did in the week to engage in activities or go out if they wished. We discussed this with the registered manager who told us of their plans to improve activities for people at the weekend.

Staff had received training appropriate to their roles and this was regularly updated. Staff told us they felt the training provided was good and that they felt supported in their roles.

We found staff had been recruited safely, and the provider operated safe recruitment processes. This included undertaking appropriate checks with the Disclosure and Barring Service (DBS) and obtaining suitable references. DBS checks provide information

including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider did not always assess or manage the risk of infection. We found areas of the service which did not allow for through cleaning as they had not been well maintained. The provider did have a refurbishment plan in place to address these issues, however work had not yet commenced at the time of our assessment.

Training records evidenced staff had received training in infection, prevention and control and staff told us of how they put this training into their day to day practice. The provider and registered manager did not conduct audits to monitor infection, prevention and control but told us of their plans to introduce this.

Records relating to the stock levels of medicine were not always accurate. We found one person’s medicine did not correspond with the stock level recorded on their medicine chart. We also found medicine administration records had not always been completed in line with best practice, for instance we found one person had not had their medicine administered at the time instructed by the prescriber, staff told us this was the person’s choice, however records did not evidence this was recorded or monitored. We also found gaps in people’s topical cream records, staff told us this was when people had declined the application of the cream, however this had also not been recorded on the medication system in place and was not in line with the providers policy.

Records for the medicine room and medicine fridge temperatures contained missing daily entries.

The registered manager told us of the actions they would take which included introducing a more thorough auditing system to identify these issues.

We found controlled drugs were safely managed, regular stocks were in place and records were fully completed. We also found protocols in place for ‘when required’ medicines, these detailed when these medicines should be offered or administered, and the signs people may display when this medicine should be considered.