Fort Horsted Care Home Ltd

We carried out this inspection in response to concerns about safeguarding and managing risks for people and to follow up on an existing breach in relation to safe care and treatment from the previous inspection (report published 27 July 2022). Improvements were not found at this assessment, and the provider remained in breach of this regulation. We also identified a new breach in relation to good governance.

Risks for people had not always been well managed. Risk assessment and care planning quality was variable. Some records were detailed and person centred, however others lacked essential information, were not sufficiently personalised or were not consistently followed in staff practices. This placed people at risk of harm, particularly in relation to repositioning, hydration, nutrition and constipation management.

The provider had not always followed local safeguarding protocols. Accidents or incidents, including those which constituted possible safeguarding concerns, had not always been robustly reviewed with sufficient action to reduce future risks. Despite this, people and relatives consistently told us they felt safe living at the service and described staff as kind, respectful and caring.

Medicines continued to not always be managed safely. We identified some medicine management shortfalls, including missed opportunities to respond to constipation risks, medicines stock discrepancies and incomplete PRN (as required) medicine protocols.

Staffing levels were sufficient to meet people’s needs, and people told us staff responded when they needed support. However, at nighttime some people and relatives described delays at night, particularly when waiting for shared equipment. We observed positive, warm interactions during our site visit, with staff knowing people well, seeking consent before providing care and supporting people’s dignity and independence.

The environment had benefited from some refurbishment since the last inspection, with improved flooring and redecorated bedrooms. However, some areas such as cleaning standards, furniture condition and laundry processes required further improvement.

Leaders were visible, approachable and committed to improving the service. There was evidence of a more open culture, improved staff morale and increased governance activity. However, systems to ensure effective oversight were not always robust, including incident analysis, safeguarding notifications, care planning and delivery checks and audit follow-up.

We have asked the provider for an action plan in response to the concerns found at this assessment.