Fieldhead Park

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes. The service was in breach of legal regulation in relation to person-centred care.

This service scored 29 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People and relatives were often not involved in care planning and reviews of care. People did not have copies of their care plans or risk assessments. One staff member told us, “No, they [the care plans] are for staff not residents. I've never seen a resident with their care plan.” In addition, we found information in care records was at times incomplete, inaccurate and conflicting.

People’s needs were not fully assessed prior to admission. This meant staff did not have the information needed to deliver person-centred care. There was no documented evidence of discussions taking place with people regarding their needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

We found examples when the service had failed to adhere to best practice guidance and therefore standards of care and people’s experiences fell below what was expected. For example, people were not being offered adequate fluids. We observed occasions whereby people were not offered a drink or were left without a drink for long periods of time. Records also showed people were not being offered sufficient fluids. For example, on 1 day, 1 person was only offered 200mls of fluid all day. Adults typically require between 1200mls and 2000mls per day. In addition, 1 person was not offered anything to drink until 15:15 in the afternoon. We raised the concerns regarding lack of fluids for people with the registered manager on the first day of the assessment. However, we observed the same issues on the second day. This placed people at risk of dehydration.

Records showed some nationally recognised assessment tools were in use to assess people’s needs and risks. However, they were not being used correctly as at times they contained inaccurate and conflicting information and were not always kept up to date.

The provider did not always work consistently well across teams and services to effectively support people.

Staff knew how to make referrals to health professionals, and we did not receive any negative feedback regarding the effectiveness of teamwork with external services. However, staff did not consistently work together to ensure people’s needs were fully assessed, monitored and accurately documented. This meant there was a risk that when information was shared it was not accurate or fully complete.

We observed examples of staff working together as a team. However, improvements were required to ensure more consistent and effective teamwork to meet people’s needs and keep them safe.

The provider did not support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control.

Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. People’s choice regarding this were limited. For example, many people were not supported to access fresh air and outdoor space to enhance their health and wellbeing. In addition, many people were cared for in bed or in their own rooms. We did not see evidence that their needs were regularly reviewed to indicate they needed to remain in bed or in their own room. One person was shouting out and told inspectors, “I want to get up. Surely, I can get up.” It was unclear from the person’s care records why they could not get out of bed.

People were not consistently empowered and supported to manage their own health, care and wellbeing needs as collaboration with them was frequently lacking.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Systems and processes were not effective in routinely monitoring people’s care and treatment to continuously improve it. Oversight was lacking with regards to monitoring care and treatment, learning lessons, taking action, and improving outcomes for people. For example, 1 person’s records showed they were not being weighed in line with their assessed needs and where 2 people had lost weight, there was no action taken to improve their outcomes. In addition, the experiences of people living with dementia had not been suitably monitored to make improvements to their care and experiences at the service.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

Where DoLS were in place, these were not managed well and systems were not in place to evidence how any requirements of the DoLS, known as conditions, were being met. Documentation regarding management of DoLS was not clear and there was a lack of robust oversight and monitoring of this.

We were not assured people were told about their rights and that people’s wishes were always respected and supported. For example, 1 person, assessed as having capacity, made a choice to smoke. However, they were restricted with regards to how often they were allowed to go outside for a cigarette. Records clearly documented the restriction was in place and showed the person had not been outside to smoke at all on 4 days and had only been outside to smoke once in 14 days in February 2025.

Staff did not always demonstrate a good understanding of mental capacity and did not demonstrate respectful views of people. For example, 1 staff member told us, “A lot of the people here don't have full capacity this is what you have to understand, they don't understand” (pointed at the side of their head as they said this). “Whilst I approach them and go have a chat. They might seem sensible, but all is not as it seems.”

People were not consistently involved in making decisions about their care and a person-centred approach to care was lacking.