Fleetwood House

Updated 7 April 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

The inspection team was made up of two inspectors who visited the service and an Expert by Experience who made telephone contact with people’s relatives and representatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Fleetwood House is a ‘care home’. People in care homes receive accommodation and nursing or 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.

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 who work with the service. 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 used all this information to plan our inspection.

During the inspection

We spent time with people, observing the support they received and how staff understood their needs. We spoke with three relatives and an advocate about their experience of the care provided. We spoke with seven members of staff including the registered manager, deputy manager and support workers.

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

After the inspection

We spoke with senior area managers to clarify their approach to quality assurance processes and recruitment and retention challenges. We continued to seek clarification from the registered manager to validate evidence found. We sought further records and information from the registered manager. We spoke with two health and social care professionals.

Updated 7 April 2022

About the service

Fleetwood House is a residential care home providing care and accommodation for people with learning disabilities. It is registered to support up to eleven people, there were eleven people living at the home on the day of our inspection.

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

We have made recommendations about staff numbers and some medicine management.

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 statutory guidance which supports CQC 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:

Right support

There were enough staff to keep people safe and occupied at home, however, regular staff shortages sometimes led to people not receiving support with going out and fulfilling activities out of the home. The provider was actively recruiting but had not been able to address long term recruitment needs.

Records of people’s support were not always up to date or completed accurately. Staff knew people well and were committed to supporting people’s choices and independence.The home environment was safe and welcoming, IPC and medicine administration was managed safely.

Right care

Risk assessments for health and emotional wellbeing did not always provide clear guidance to staff and were not always up to date. This placed people at risk of support errors or changes in needs being missed. However, people experienced support which was kind and caring, staff were well supported with training and development opportunities and were committed to person centred care. People were encouraged to make their rooms personalised and homely. People’s relatives saw their loved ones were happy with their support and treated with dignity and respect.

Right culture

Management oversight did not always ensure records and processes were followed, this sometimes prevented the professionals supporting people to have confidence that plans and actions were being carried out effectively.

Staff understood the values of person-centred and respectful care and felt supported by managers to provide this. People’s relatives felt managers and staff were approachable. People were relaxed and comfortable in the company of staff.

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

Rating at last inspection

This service was registered with us by a new provider on 25 September 2020 and this is the first inspection since then. The last rating for the service under the previous provider was good, published on 1 April 2020.

Why we inspected

This was a planned inspection because the service had not been inspected since registering under a new provider.

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 COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

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

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 monitor the service and will take further action if needed.

We have identified breaches in relation to how people's care needs were updated in their plans and the level of governance in place to monitor people's risks and safety.

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