Frome Care Village

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At the last inspection in May 2023 the provider was in breach of regulation 17, Good Governance, of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because they had failed to ensure systems and processes were effective at monitoring and improving the quality and safety of the service The provider had made some improvements but not enough to meet the breach of regulation. This was because, where they had identified concerns through their monitoring process, there was not an effective process in place to action improvements. After our formal feedback to the provider, we met with them and they told us about the actions they were taking in response to our feedback. This included putting in place online monitoring forms for clinical and health and safety checks, to improve remote oversight. They also implemented learning across their other homes in relation to managers oversight checklist completion and weekly meetings with senior management. Staff said they tried to create a positive, homely and compassionate atmosphere. They were committed to providing the best care and support they could to each person and improve where they could. The provider’s policies and procedures encouraged people, staff and relatives to speak up through different channels. The majority of the staff told us they were treated equally and felt the home was inclusive. People, relatives and staff were positive about the manager. Since we undertook our site visit for this assessment the manager has been registered with CQC as the registered manager. People and relatives told us healthcare professionals were contacted by the home and visited regularly. Staff understood when people needed input from healthcare professionals.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff said they tried to create a positive, homely and compassionate atmosphere. They were committed to providing the best care and support they could to each person and improve where they could. One staff member said, “The rationale and methods used here are brilliant. People are treated as family here.” Another staff member told us, “I think the care is good; we are a good team. I would be happy for my relative to live here.”

Staff spoke with relatives when they visited and there was a relative communication document. However, records showed relatives meetings do not happen regularly. The provider had identified this an area for improvement at their monitoring visits, but a meeting had still not been held. The provider had undertaken a survey to ask relatives about their views of the service. The feedback concluded in June 2024 and recorded that some areas required improvement. For example, in particular communication by the staff team, people being supported to be comfortable and not feeling able to recommend the home. At the time of the assessment, no formal plan of action was in place regarding these findings. However, we were told about the manager working with staff around the mealtime experience.

We received positive feedback from staff about the management at the home.

Since we undertook our site visit for this assessment the manager has been registered with CQC as the registered manager. The registered manager from the providers other home in the area and one of the providers were supporting the manager in their role and development. The provider requires the manager to complete a manager’s role and responsibilities checklist each month. The tool is to ensure all areas are being managed well, overseen and any shortfalls are picked up and prioritised. This had not been completed consistently at the beginning of 2024. This had been identified by the providers monitoring visits but the action to have them completed had not consistently happened.

The majority of staff told us they were comfortable raising concerns with the manager and were confident their views were listened to. They knew who to raise concerns with, both within and outside of the organisation. One staff member said, “I have never had any concerns; I would say if I had. I think there are lots of ideas and information sharing. Anything that is said is listened to and taken on board.” Another said, “[Manager] is very approachable, spot on, no problems at all.” Some staff said they felt discriminated against and felt vulnerable at the home, which they told us they had raised at a staff meeting in May 2024. We discussed this with the management team and they acted upon this feedback.

The provider’s policies and procedures encouraged people, staff and relatives to speak up through different channels. People, staff and their relatives were provided with opportunities to raise any comments via an open-door policy at any time.

The majority of the staff told us they were treated equally and felt the home was inclusive. Staff told us staff meetings were held but not regularly. However, they confirmed senior staff attended regular meetings and they felt supported.

The provider told us in the provider information return, “ The home ethos is that no judgement or discrimination will be made to anyone either living with us, coming into the service as a visitor or someone that works with us. We strive to support anyone to feel comfortable within their surroundings.” The service employed overseas workers. As part of this, there were processes in place for checking visas and staff’s right to work in the UK.

Staff spoken with felt that improvements had been made since the last inspection. They told us they were aware of their job descriptions and their role expectations. The registered manager and the providers senior management team were very responsive to the concerns raised at this assessment. They were open in acknowledging improvements were needed in their governance processes. People and relatives were positive about the manager. One relative said, ‘(Manager) is fantastic, she knew how anxious I was and offered me a pull-out bed until she settled, I do trust them now.”

At the last inspection, the providers systems and processes for monitoring and improving the quality and safety of the service were ineffective. We identified concerns relating to cleanliness, the deployment of staff, and the delivery of person-centred care. The provider's quality monitoring systems had not identified theses. At this assessment we saw there had been improvements, with dedicated care practitioners allocated to each unit which enabled the nurse to provide clinical oversight and guidance to both units. The cleanliness of the units had improved. However, although staffing levels had been increased since our last inspection at the home, people, relatives and staff told us that on the Woodland unit, there were not enough staff to support the needs of people promptly. Since our last inspection, the provider had increased the care staffing level on Woodland to five in the daytime. However, during the month of June 2024, on twelve occasions this was not the case. The provider had completed monitoring visits and had identified areas for improvement and had put in place actions. These actions had not always been acted upon. For example, 6 staff had been identified as not having completed mandatory training in April 2024 by the end of June 2024 these staff had still not completed all their mandatory training. It was identified in July 2023 no relatives meeting had been held and the monthly manager’s role and responsibilities checklist had not been completed. In January and April 2024 these were still not completed. Gaps in the home’s maintenance monthly health and safety checks had been identified and not been acted upon promptly. Therefore, the provider remains in in breach of Regulation 17. However, in May 2024 the providers monitoring visit identified poor care provision for some people on the Woodlands unit. Actions were put in place to improve monitoring of people’s care by the onsite management, which was improving care provision.

People and relatives told us healthcare professionals were contacted by the home and visited regularly. A relative told us, “The manager is very open to how things are and will explain to the relatives any staff changes before they are implemented so it isn’t a surprise.”

Staff understood when people needed input from healthcare professionals. A weekly visit from the local GP surgery was undertaken to see people, staff had concerns regarding.

Health and social care professionals raised concerns about being able to undertake reviews. One told us, “Booking appointments or contacting the home is always challenging with Evolve. They do not like us to contact the home directly for any reason and ask us to book via their management team for assessments.”

The provider had identified the impact on people and staff with the number of health and social care reviews required by external agencies each year. They had implemented a policy to only undertake planned reviews. This required external agencies to book appointments to undertake a review. This was so the provider could ensure the health and social care professional had the care records they required and had a designated staff member available at the planned appointment. We were told this policy was on the providers website but was not visible at the time of the assessment. We were told this was made accessible.

Staff said the home manager, nurses and senior members of staff were visible and led by example. One staff member said, “The manager I get on well with, she has a really good understanding of what we go through on the floor. It's nice to have that and it's important. We work well with nurses.” Where improvements were needed, primarily in nursing care, the provider had ensured extra support was being provided to the management team. One staff member told us, “Staff genuinely care, but a lot of clinical improvements are required. The right clinical culture is not here yet, but I have seen improvements in the time I have been here.”

The provider told us in the provider information return, “The company will also review things across all Evolve homes and put learning out to everyone, for example: if an incident has occurred in another home and learning has come from that incident then this will be echoed across all homes. This will allow potential risks to be mitigated before they occur.”