Finch Manor Nursing Home

We undertook this assessment to follow up on breaches of regulation we found at our last assessment. The provider was previously in breach of legal regulation in relation to safe care and treatment, safeguarding people from abuse and improper treatment, staffing, person‑centred care and good governance.

Improvements were found at this assessment; the provider was no longer in breach of safeguarding people from abuse and improper treatment, staffing and person‑centred care regulations. The provider remained in breach of safe care and treatment specifically in relation to medication management and good governance. We also found the provider in breach of the regulation need for consent.

Medication was not managed safely; clinical governance, processes and systems for medication management were in place but poorly followed and maintained. Audits had identified some of the issues we found but these had not been addressed. Governance systems relating to the oversight of medication management were not effective. Some of the medication concerns we found had been identified at our previous assessment but not addressed, and any improvements had not been sustained.

We found a small number of assessments where people lacked capacity to make specific decisions; we found some assessments and best interest decisions which were not appropriately completed and did not involve relevant professionals and relatives where appropriate. We requested the provider submit an action plan following the assessment.

People were supported by knowledgeable staff who understood their needs and promoted their health, wellbeing and independence. Incidents and safeguarding referrals had reduced; staffing levels were sufficient, and care plans and risk assessments provided guidance to support people effectively and safely. People were treated with kindness, dignity and respect, and were encouraged to make choices about their daily lives. Staff knew people well and delivered personalised care. Staff spoke positively about the service and felt supported by the management team, contributing to a positive and well-led culture.

Improvements had been made to strengthen governance, safety, the quality of care provided and staff wellbeing.

Clinical governance arrangements had been reviewed and enhanced through the introduction of revised processes and frameworks, aimed at improving the quality of care and clinical outcomes for people.

Oversight systems had been implemented to ensure environmental risks were mostly identified, monitored, and addressed promptly, with historic actions reviewed and outstanding issues resolved. The environment was clean and the provider was in the process of a refurbishment and upgrade plan.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.