About the service Florence House is a residential care home providing personal care and accommodation to 31 people aged
50 and over at the time of the inspection, some of which were living with dementia, a physical disability,
sensory impairment or needed support with their mental health. The service can support up to 36 people in
a single adapted building.
People’s experience of using this service and what we found
Systems were not effective at identifying areas that needed improving in a timely manner. Risks were not
always assessed, planned for and mitigated to keep people safe as assessments were not always
personalised.
The registered manager failed to ensure that people’s care records were accurate and up to date. The registered manager did not undertake audits of people’s care records.
Systems were not in place to manage medicines safely. Medication audits had been completed, however, they failed to highlight issues that were found during the inspection.
Ineffective quality assurance systems meant that the provider could not always continuously learn, improve and innovate. We found the registered manager did not complete any audits that focused on accidents and incidents in the service.
The service was clean and free of malodour. There were a number of personal protective equipment (PPE) stations positioned throughout the home and staff wore appropriate PPE.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The rating at the last inspection was requires improvement (report was published on 22 August 2019). You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Florence House on our website at www.cqc.org.uk.
Why we inspected
We received concerns in relation to people's personal care and how the service was promoting people's
safety. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
The ratings from the previous comprehensive inspection for those key questions not looked at on this
occasion were used in calculating the overall rating at this inspection. The overall rating for the service has
remained the same.
Follow up
We identified concerns at this inspection. We will therefore aim to re-inspect this service within the published time scale for services rated requires improvement. We will continue to monitor the service through the information we receive.
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 two breaches. Regulation 12 the registered person failed to ensure risks relating to the safety, health and welfare of people using the service were assessed and managed safely and the registered person failed to ensure the proper and safe management of medicines. Regulation 17 The registered person had not established an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan for 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.