Archived: Fulwood Lodge Care Home

Updated 15 May 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 23 March 2018 and was unannounced. The inspection team was made up of one adult social care inspector, one expert by experience and a specialist advisor. The specialist advisor was a nurse with experience of working with older people. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert by experience had experience in caring for older people and people living with dementia

Before this inspection we reviewed the information we held about the service, which included correspondence we had received and any notifications submitted to us by the service. A notification must be sent to the Care Quality Commission every time a significant incident has taken place. For example, where a person who uses the service suffers a serious injury. We received two complaints regarding possible neglect of people living at Fulwood Lodge. As a result we brought this inspection forward and the areas of concern were looked at as part of this inspection. The registered provider met the minimum requirement of completing the Provider Information Return (PIR) at least once annually. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. However, as the inspection was brought forward the information in the PIR was not recent enough to help with the planning for this inspection and to support our judgements.

Before our inspection we contacted members of Sheffield City Council contracts and commissioning service and the NHS Sheffield Clinical Commissioning Group. They told us they continued to jointly monitor the service and support the registered provider to improve as they had concerns regarding the quality of support provided to people who used the service.

During this inspection we spoke with 11 people who lived at Fulwood Lodge and three relatives who were visiting at the time. We met with the registered manager and the registered provider. We spoke with eight members of staff. We spent time observing daily life in the service as well as looking at written records, which included five people’s care records, six staff personnel files and other records relating to the management of the service.

Updated 15 May 2018

This inspection took place on 23 March 2018 and was unannounced. This meant no-one at the service knew we were planning to visit.

We checked progress the registered provider had made following our inspection on 5 July 2017 when we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in; Regulation 10, Dignity and respect; and Regulation 17, Good governance. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009, Notification of other incidents.

Following the last inspection, we asked the registered provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, responsive, caring and well-led to at least good. We found improvements had been made and the registered provider was no longer in breach of regulations.

Fulwood Lodge is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Fulwood Lodge is a 42 bed home providing personal and nursing care to older people with a range of support needs, including people living with dementia. There were 27 people living at Fulwood Lodge at the time of this inspection.

There was a registered manager employed at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People we spoke with told us there had not been a wide range of activities or outings in recent months. However, people also told us the newly employed activity coordinator was committed to introducing activities that were enjoyable and beneficial for everyone’s health and wellbeing. We recommend the registered provider ensures these recent improvements are sustained and developed to meet everyone’s needs.

People were usually supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff clearly knew people and their likes and dislikes, however on occasion staff did not ask for consent or give people options before providing care and support. We spoke with registered manager and registered provider about this.

Staff understood what it meant to protect people from abuse. They told us they were confident any concerns they raised would be taken seriously by the registered manager.

There were enough staff available to ensure people’s care and support needs were met. The registered provider had effective recruitment procedures in place to make sure staff had the required skills and were of suitable character and background.

Medicines were stored safely and securely, and procedures were in place to ensure people received their medicines as prescribed.

We saw the premises were clean and well maintained.

People and their relatives told us they enjoyed the food served at Fulwood Lodge, which we saw took into account their dietary needs.

Positive and supportive relationships had been developed between people, their relatives, and staff. People told us they were treated with dignity and respect.

People’s care records reflected the person’s current health and social care needs. We saw these were evaluated monthly by staff and we were told six monthly reviews were to be introduced involving the person and their relatives.

There was an up to date complaints policy and procedure clearly displayed in the reception area. People, their relatives and staff told us the registered manager was approachable and responsive to any issues raised.

People living at Fulwood Lodge and staff were regularly asked for their views. Concerns and suggestions were considered and acted upon.

There were effective systems in place to monitor and improve the quality of the service provided. Safety and maintenance checks for the premises and equipment were in place and up to date.

The service had up to date policies and procedures which reflected current legislation and good practice guidance. However, some of them needed amending to include information and local contacts specific to Fulwood Lodge.