Archived: Mary Fisher House

Updated 13 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. 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 undertaken by two inspectors.

Service and service type

Mary Fisher House is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Mary Fisher House is a care home without nursing care. 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who worked with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

During the inspection

We spoke with seven people who used the service and two visitors to the service about their experience of the support provided. We also spoke with a healthcare professional. We spoke with eight members of staff. This included a senior carer, care assistant, registered manager, deputy manager, activities worker, housekeeper and agency worker. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a wide range of records. This included four people’s care records and multiple medication records. We looked at three staff files in relation to recruitment, induction and supervision. A variety of records relating to the monitoring and management of the service, including policies and procedures, were reviewed.

After the inspection

We continued to seek clarification from the provider and registered manager to validate evidence found. We received further evidence by email which we reviewed including risk assessments, policies and procedures, agency profiles and rotas.

Updated 13 August 2022

About the service

Mary Fisher House is a residential care home providing personal and nursing care for up to 24 people. At the time of our inspection there were 20 people living at the service. Mary Fisher House provides support to people aged over 65, some of whom live with dementia.

Accommodation is provided in one building across four floors which people could access through use of stairlifts and a passenger lift. Each bedroom had an ensuite toilet and sink and there were two shared bathrooms. People had access to some communal spaces including a living room and dining room.

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

Parts of the premises had not been well maintained and were unsafe. There were fire doors, with large gaps underneath, which had been awaiting replacement since the previous inspection in April 2021. There had been longstanding issues with the hot water supply, which the provider had started to address. We observed damaged radiator covers, exposed light fittings and exposed woodwork which could cause harm to people. Parts of the building were not clean, including some bedrooms which smelt strongly of urine, and the kitchen, which had evidence of rodent droppings.

Staff infection prevention and control practices were not robust or in line with government guidance. Personal protective equipment (PPE) was not always disposed of safely, staff were observed to move their masks below their nose and mouth and were not always bare below the elbow.

Risk management processes were not well established or reliable in ensuring that risks to people were assessed and actions taken to mitigate these. When accidents and incidents occurred, these were not always recorded or followed-up.

Medicines practices were unsafe. There were occasions whereby people who used the service had received their medicines late or had not been given them, as there were none left. Sufficient and timely actions were not taken to address this. A medicines policy was in place, but staff practice was not always in line with this. Staff who administered medicines had not always been trained.

There were insufficient staffing levels to safely support people. People told us there wasn’t always enough staff to meet their needs in a timely manner including with medicines support and to provide meals. There had recently been a high turnover of staff and, at the time of our inspection, there was a strong reliance on agency staff. Agency staff had not completed an induction to ensure they could safely work in the service and understood people’s needs.

People were not supported to have maximum choice and control of their lives and were not always supported in the least restrictive way possible and in their best interests. People’s consent had not always been sought and mental capacity assessments had not been consistently completed when there were concerns about a person’s understanding.

Staff had not consistently received training in important areas such as safeguarding and moving and handling. Staff who worked in the kitchen, preparing food, did not have always have training to ensure they understood the requirements of this role. We received generally poor feedback about the standard of food. When new staff started, they did not always complete a robust induction or have regular supervisions.

Elements of staff practice did not promote people’s dignity, including not disposing of continence aids appropriately. Staff were observed to be polite in their interactions with people and worked hard to try and meet people’s needs.

Pre-admission assessments and care plans were not always in place for people who lived at the service. This meant there was limited information to guide staff about people’s needs and how to support them. Due to the low staffing levels, staff did not have the time to meaningfully engage with people and most interactions were task-based, focused on assisting with personal care, eating etc. During our inspection we observed no activities with people with people appearing to spend much of their time sitting or watching television quietly.

A series of checks were completed by the registered persons. However, these had failed to highlight and address the issues noted on this inspection, which meant people were at risk of harm.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 16 June 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels, medicines practices, personal care provided to people and management of the premises. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report. Following our inspection, the provider started to work with local authority agencies to begin making the necessary improvements and to mitigate the most serious risks.

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have identified breaches in relation to consent to care, safe care and treatment, premises and equipment, staffing and good governance at this inspection. We took enforcement action but this did not proceed to the final stage.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.