Fitzwarren House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always promote a positive culture of safety or consistently use incidents, feedback and quality assurance processes at location level to identify learning opportunities and drive improvements. Risks associated with behaviours displayed by some people had not always been fully assessed, including the potential impact on others. We also identified concerns relating to fire safety, which had not been effectively identified and addressed through the provider's oversight systems. This meant opportunities to learn from incidents, identify emerging risks and take action to reduce them were not always recognised or acted upon.

Despite this, people and staff did not raise any concerns about safety, learning or the way incidents were managed within the service. Learning was shared through regular 'Toolbox Talks', which included lessons learned from internal and external incidents. For example, following a choking incident at another service, staff were reminded about safe food preparation, accurate recording of dietary requirements and the risks associated with dysphagia. These examples showed the provider had systems in place to share learning and promote safer practice, although these were not always consistently effective at location level.

The provider worked collaboratively with people and healthcare professionals to maintain safe systems of care and support continuity when people moved between services.

People's health needs were documented, and referrals were made to relevant healthcare professionals when required. The provider told us that, where possible, the assessor who completed the pre-admission assessment was present when people moved into the service. This helped support a smoother transition and ensured information gathered during the assessment process was shared effectively with staff involved in providing care.

One person told us, “The moving in process went smoothly”.

Professionals told us the service provided good continuity of care and that referrals to other professionals and services were generally made without delay.

The provider did not always work effectively with people and healthcare partners to understand what being safe meant to people and how this could be achieved. They did not always identify and respond appropriately to risks that could impact people's safety and wellbeing.

We found the provider had not always recognised or escalated concerns where the suitability of a person's placement presented a risk to their own safety and the safety of others. Whilst incidents relating to a person's behaviours had been documented and reported, the provider had not made safeguarding alerts to the local authority safeguarding team. We raised these concerns with the leadership team and shared relevant information with the local authority.

This meant opportunities to take additional action to reduce the risk of harm to the person, and others, may have been missed.

Deprivation of Liberty Safeguards (DoLS) applications were made where required, and systems were in place to monitor and track applications and authorisations.

Staff had received safeguarding training, and the registered manager told us safeguarding awareness formed part of the recruitment process for all staff roles.

The provider did not always detect and control potential risks in the care environment. Systems and processes were not consistently effective in identifying, assessing and mitigating risks, which meant the provider could not always be assured that people received safe care and support.

We found the provider had not fully assessed the risks associated with behaviours displayed by some people living at the home, including the potential impact of these behaviours on others. This meant that opportunities to identify, understand and reduce potential risks had not always been taken. We raised these concerns with the leadership team, who acknowledged the issues identified and agreed to review and reassess risk management arrangements to ensure risks were appropriately identified, assessed and mitigated.

Records showed regular use of PRN (when required) medicine to support a person experiencing distress. However, there was no Behaviour Support Plan in place to guide staff on potential triggers, early signs of distress or preferred de-escalation strategies. Whilst staff were able to describe actions they took before PRN medicine was administered, records did not consistently demonstrate a structured approach to understanding and responding to the person's distress.

The provider's senior leadership team had identified patterns and trends relating to these concerns through their quality assurance processes and had provided additional support to the service. However, at the time of the assessment, improvements were not fully embedded or sustained.

The provider did not always identify and control potential risks within the care environment or ensure that systems, facilities and equipment consistently supported the delivery of safe care.

We identified concerns relating to fire safety arrangements. Staff we spoke with were not always clear about the designated fire evacuation assembly points. Records showed that previous mock fire drills had identified areas requiring improvement; however, the manager was unable to confirm whether all actions had been completed.

Staff knowledge and the provider's oversight of actions arising from fire drills were not always sufficient to demonstrate that fire safety arrangements were consistently effective.

This meant the provider could not be fully assured that all fire safety risks had been effectively identified, monitored and addressed to keep people safe.

However, leaders told us that an independent fire safety assessment had recently been completed by an external contractor and they were awaiting the findings and recommendations of the report.

The provider had completed Personal Emergency Evacuation Plans (PEEPs) for people living at the service, outlining the support individuals would require in the event of an emergency.

The provider did not always ensure there were enough suitably qualified, skilled and experienced staff deployed to meet people's needs safely and effectively.

The provider used a dependency tool to determine staffing levels. However, the tool did not always reflect people's current needs or levels of dependency. We raised this with the manager, who acknowledged our concerns and agreed to review and update the dependency assessments on the same day.

This meant the provider could not be assured it was deploying sufficient numbers of suitably skilled staff to meet people's needs.

People expressed concerns about staffing levels. Comments included, “I don't think there's enough staff,” and, “There aren't enough staff here, both day and night.” Staff also raised concerns, particularly during periods of sickness absence and annual leave. One staff member told us, “Sickness and a lack of cover increases the pressure, especially when other members of staff are on annual leave.”

Healthcare professionals told us staffing levels on the nursing unit were generally sufficient to meet people's needs. However, concerns were raised that staffing levels and staff knowledge on the residential dementia unit did not always reflect the complexity of people's needs. One healthcare professional told us additional learning opportunities had been offered to support staff in recognising and responding to physical deterioration, but these had not been fully taken up. Another highlighted a need for further training and support for staff working on the residential dementia unit, including recognising signs of deterioration, sepsis and infection, and understanding when concerns should be escalated to ensure people received timely care and treatment.

We discussed this with the manager, who confirmed the training had been highlighted to the service, but no plans had been put in place at that time to deliver it. They told us the organisation had since obtained the training materials and planned for the service's nurse to deliver the training to senior care assistants.

During our assessment, we observed 2 occasions where staff were interrupted during care and support to assist visitors entering the service. This resulted in people being left waiting in their wheelchairs while staff attended to other tasks. Managers told us this was due to staff sickness on the day of the assessment.

The provider had systems in place to monitor staffing levels and identify training needs. However, staffing arrangements and training provision did not always ensure staff were equipped to meet the changing and complex needs of people living at the service.

The provider did not always effectively assess and manage risks relating to hygiene and environmental cleanliness.

Some areas of the home were malodorous. We raised this with the provider, who told us carpet replacements were planned over the coming months to address the issue. Whilst the provider had identified actions to improve the environment, the condition of some areas meant people were at increased risk from the spread of infection.

People raised concerns about cleanliness and housekeeping resources within the service. One person told us, “There aren't enough cleaners”. A relative said, “Some decoration is very tired, paintwork,carpeting, but this is a secondary concern for us.”

However, staff had received infection prevention and control (IPC) training and had access to appropriate personal protective equipment (PPE). We also observed domestic staff carrying out cleaning duties throughout the assessment.

The provider did not always ensure medicines and treatments were managed safely or in a way that fully reflected people's needs, capacities and preferences.

Some people were prescribed high-risk medicines, including anticoagulants (blood thinners). Whilst risk assessments were in place, these did not always provide staff with sufficient information about associated risks, signs of deterioration, or the actions required to keep people safe. This increased the risk that staff may not be able to respond appropriately should concerns arise.

Some people were prescribed flammable emollient creams; however, the provider failed to consistently assess this risk. This issue had previously been identified through the provider's own audit processes but had not been fully addressed.

This meant the provider could not be assured medicines-related risks were consistently identified, assessed and managed

However, staff had completed medicines administration training and their competency to administer medicines was assessed annually. Medicines were stored securely and records demonstrated people generally received their medicines as prescribed.

People, relatives and healthcare professionals did not raise any concerns about the management of medicines within the service.