Faycroft

Updated 30 October 2021

The inspection

This was a targeted inspection to check whether the provider had met the requirements of the Warning Notice in relation to Regulation 17 (Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

This inspection was carried out by one inspector.

Service and service type

Faycroft is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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 present the registered manager is not in work and the home is being supported by a peripatetic manager.

Notice of inspection

This inspection was unannounced.

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 prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with four people who used the service and observed the care of all the people living at Faycroft. We spoke with four members of staff including the provider, manager, and care workers.

We reviewed a range of records. This included three people’s care records and multiple medication records. We also looked at a variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at policies and quality assurance records.

Updated 30 October 2021

About the service

Faycroft is a residential care home providing personal to six people with a learning disability at the time of the inspection. The service can support up to seven people.

The home is split over two levels with the majority of bedrooms and bathrooms on the first floor. Downstairs people have access to communal facilities, and a secure garden. The home is located close to local amenities.

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

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not supported this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. A closed culture had begun to develop. A closed culture can be described as a poor culture where the risk of harm is increased due to a range of different factors such as, poor leadership and restrictive practice.

People were not always protected by the systems in place and risks to their safety were not always considered. Accident and incident forms were completed and reviewed but lessons were not always learnt. The guidance in place for the administration of ‘as required’ medicine was often generic and did not give clear enough guidance to ensure it was given at the right time. The audits and process in place had not identified all the issues found prior to recent concerns being raised.

People were supported by sufficient numbers of staff who were recruited following a check to their background, qualification and character.

We were somewhat assured by aspects of how the home was able to manage the risks associated with COVID -19 such as visitor access and touch cleaning. We were assured by the use of personal protective equipment, COVID -19 testing, and the homes ability to manage a potential outbreak.

People’s care needs were not always clearly defined, and gaps were noted in the care planning process. Staff were trained in subjects relevant to their role, but we found limited evidence of specialist training especially around mental health.

People were supported to access enough to eat and drink, but we questioned whether all people were being supported to have a balanced diet. The staff worked with other agencies and plans were in place to improve the environment.

People were observed being treated with kindness and respect. However, we found aspects of people’s care plan that recommended a dedicated time to talk had not happened consistently. People were able to express their views on a daily basis and their independent living skills were promoted.

The provider was able to demonstrate an understanding of their duty of candour and was working with other agencies to improve the quality of care people received.

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

Rating at last inspection

The last rating for this service was good (published 17 April 2019).

Why we inspected

The inspection was prompted in part due to a specific incident and concerns received about the processes in place to protect people from harm, the management of risk, leadership and culture. A decision was made for us to inspect and examine those risks. The specific incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

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 coronavirus and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring and well-led sections of this report.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to people being safe from potential abuse, safe care and treatment, consent and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.