Firbank House

The service did not manage medicines safely because the systems and processes in place for managing medicines were not always effective.

We found no evidence that people were harmed at the time of the inspection because harm is not always immediate, but people were placed at increased risk of harm because medicines were not managed safely.

Accidents and incidents were reviewed however further analysis was required. Care plans were not always updated in response to accidents and incidents. Care plans did not always clearly outline people’s risks and how staff should support them safely. Appropriate health and safety checks were in place in relation to equipment at the service. There was damage to the flooring in both communal areas and people’s own rooms. This presented both a potential trip hazard and infection prevention and control issue.

The concerns demonstrated a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was a fire risk assessment in place at the service. Actions had been taken in response to the fire risk assessment, however these had been completed outside of the recommended timeline given. There were records of incidents when the fire alarm had been triggered however there were no fire drills taking place at the service. Fire drills are essential and help a service test their procedures and determine any additional learning required for staff.

Staff were recruited safely. Staffing levels appeared in line with the staffing dependency tool. Some staff had low training compliance. This was brought to the attention of the registered manager and addressed following our site visit.

The assessment of people’s need prior to their admission to the service was not always clearly recorded or updated following incidents at the service or a change in their need.

We observed kind and caring interactions between staff and people living at the service We received mixed feedback from people around their interactions with staff. Care notes indicated that staff didn't always know how to support with distressed behaviour.

Audits at the service were not always effective. The audits had not identified concerns found during the assessment process. Maintenance audits demonstrated that action to make improvements took a significant period of time to implement. Action plans were not effective or suitably robust to drive improvement at the time of assessment.

This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Staff and people spoke positively about the registered manager. They felt able to approach the registered manager with concerns and felt they would take appropriate action.