Fremington Manor Nursing and Residential Home

Updated 26 January 2023

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 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 two Inspectors.

Service and service type

Fremington Manor Nursing and Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Fremington Manor Nursing and Residential Home is a care home with nursing care. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 the time of our inspection there was no registered manager in post. The provider had appointed a new service manager on 8 November 2022 who had commenced the process to register as the manager with the CQC.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the Provider Information Return (PIR). 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. We also reviewed additional information we held about the service, this included previous inspection reports and statutory notifications. A statutory notification contains information about certain incidents and events the provider is required to notify us about by law.

During the inspection

We spoke with ten members of staff which included the service manager, the deputy manager, clinical staff, care staff, activities staff and administrative staff. We spoke with nine people who lived at the service and observed interactions between people and staff.

We met with four people’s relatives. We reviewed a range of records, including people’s care records, staff recruitment files, records relating to safety checks including fire safety and accident and incident records. We also reviewed medicines records and records relating to monitoring and quality assurance.

Following our site visit we contacted the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also contacted another person’s relative. We contacted three healthcare professionals to seek their views on the service and received feedback from one of them. We also received further clarification and documentation from the service to validate evidence found.

Updated 26 January 2023

About the service

Fremington Manor Nursing and Residential Home is a residential care home providing personal and nursing care to 48 people aged 65 and over at the time of the inspection. The service can support up to 60 people.

The service is a large country manor house which has been extended and adapted to meet the needs of people who are frail and elderly. There are passenger lifts to all floors with bedrooms on two floors and mainly communal spaces on the ground floor. There are level access garden areas.

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

The current deployment of staff within the service had not ensured people’s needs were consistently met. All of the people and relatives we spoke with told us they currently felt staffing levels at the service did not ensure people’s needs were met in a timely way. People gave examples of how the current staffing levels had impacted them. Staff feedback in relation to staffing levels was also consistent in that the current numbers did not ensure care was consistently and safely provided.

The current governance systems in operation had not identified the areas of concern we found during the inspection. There were both service and provider level monitoring systems in place but neither had resulted in the identification of failings or change to staffing deployment. Following the inspection, we raised immediate concerns with the provider about staffing. Immediate steps were taken by the provider to review staffing dependency levels and an action plan was produced and sent to the Care Quality Commission (CQC).

People were cared for by staff who understood their responsibilities to safeguard them. There were systems in place to ensure medicines were ordered, stored, administered and disposed of safely. People’s individual care and treatment needs were planned and were reviewed regularly to ensure the support provided reflected their current needs.

The service environment was effectively maintained to ensure people were supported safely. Infection control measures within the service promoted people’s health, safety and welfare. There were no restrictions on visiting at the time of the inspection in line with government guidance.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. There were systems in place that ensured people who were deprived of their liberty were done so with the appropriate legal authority.

There was effective governance in place around incidents and accidents, the service environment and care planning. The service manager had recently commenced employment with the provider and was new in post. They were currently looking at ways to engage with people, their relatives or representatives and staff to enhance the service. There were links with the local community established for the benefit of people living at Fremington Manor Nursing and Residential Home.

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

Rating at last inspection and update

The last rating for this service was Good (published 4 September 2021).

Why we inspected

The inspection was prompted in part due to concerns received about staffing. A decision was made for us to inspect and examine those risks.

We also 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 COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to staffing and good governance.

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

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

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.