Archived: Fitzwilliam Care Centre

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. This is the first assessment for this service. This key question has been rated 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.

The service was in breach of legal regulation in relation to providing safe care and environments, effective management of risks, staffing, staff training, and the way people’s medicines were managed.

This service scored 44 (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 have a proactive and positive culture of safety based on openness and honesty. The manager did not always listen to concerns about safety and did not always investigate and report safety events. Staff told us they were supported to reflect on incidents when things had gone wrong but we found lessons learnt were not always identified and measures to reduce risks not always recorded or implemented. For example, in relation to safe medicines management. This meant people continued to be placed at risk of avoidable harm.

The staff team worked with people and healthcare partners to establish and maintain safe systems of care, in which health was managed or monitored. They made sure there was continuity of care, including when people moved between different services. They used a hospital care plan called a hospital passport to share with medical professionals when someone attended hospital. They ensured health professionals were contacted for advice or treatment when they noted signs of ill health. For example, supporting a person to access an emergency dentist and contacting district nurses.

Leaders did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Leaders did not share or act upon concerns quickly and appropriately. During the inspection, we became aware of allegations of abuse which we reported to managers and the local authority safeguarding team who are investigating. The manager failed to act appropriately to safeguard people at risk of avoidable harm. The service had been investigated for 10 other safeguarding concerns, all of which were upheld and leaders were found to be at fault of causing avoidable harm to people. A professional told us they had concerns about significant gaps in the knowledge of leaders, their lack of transparency and failure to act appropriately such as not reporting to the required authorities and failing to investigate allegations of abuse. Another professional told us, “There has been a lack of oversight of leaders (medication management) and this led to the overuse of [as and when needed] medication on a person when there were no justifications for its usage at all. (This is what is called chemical restraint). Following our input it has gone from being used 3-4 times daily to twice in 6 weeks on the rare occasion de-escalation techniques do not work.”

For people who had a DoLS authorisation approved, the provider had failed to ensure the correct authorisation forms were in place. This meant staff could not be sure what restrictions had been agreed on or if there were any conditions attached to the authorisation. These were sought and put into place during the inspection following the inspector raising the concern.

Despite our findings, people gave mixed feedback about their safety. Concerns raised were mostly due to people feeling threatened by other people who were living with dementia and become confused. One person told us, “There are 2 [people] from the other unit who wander in, in the middle of the night and it’s a bit threatening. [A person] opposite had their wallet taken by one of them, the other week.” Positive views were mainly due to staff care. One person said, “I feel secure as the staff make you feel safe.”

Relatives also had mixed views. Some relatives thought their family members were safe and others felt they were not always safe due to lack of staff who were skilled to safely support people living at the home. Staff did have a good understanding of what abuse looked like and were confident to report concerns to managers but were not all aware of who else they could report concerns to such as the local authority safeguarding team and CQC. The new manager was working with the local authority to make improvements and develop awareness.

The provider failed to evidence how they had reduced the risks of known conditions. Records did not promote meeting people’s needs in a way that was safe. Risk assessments were not always accurate or detailed enough to provide staff with sufficient guidance to support people safely and minimise the risk of avoidable harm. This included risks related to conditions such as Dementia, Down’s Syndrome, Cerebral Palsy and Stroke. Risk assessments in place for 2 people living with epilepsy gave unclear and contradictory information about when staff should contact emergency services. Staff did not know the correct process to follow should those 2 people have a seizure. Nor were all staff aware of the signs to look out for which suggest a deterioration in people’s health. A professional told us, “Risk assessments are in place, but these could be detailed further than they currently are, this has been expressed to the home and will be reviewed at the next improvement plan meeting.”

People and relatives were concerned about the staff’s skills to safely support people who were living with dementia. A relative told us, “Staff are not trained. It’s continuously happening. When I turned up a [person] was shouting and screaming at my [family member]. A [staff member] was cradling my [family member] because they were so frightened. It’s horrendous.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Call bell systems in place did not have a function to enable the managers to monitor the wait times people experienced. Managers were not using other ways to monitor how effectively staff were responding. This meant managers were unable to identify concerns people told us in relation to wait times for personal care support. The environment was clean and tidy and well furbished, but the design of the service did not consider ways that could better support people living with dementia to be aware of their surroundings, locate their own bedrooms and reduce risk of falls. This impacted how safe people felt their environment was. People told us they felt unsafe when people came into their bedrooms by mistake and took their belongings, particularly at nighttime. The provider was investigating a concern highlighted in their fire risk assessment about structural movement of the building and how this could be resolved to ensure the building remained safe. People told us they had requested grab rails in their bathrooms multiple times as they felt unsafe and at risk of slipping but nothing had yet been done about it. A person said, “I wouldn’t mind a rail in the bathroom to hold onto while I’m in the shower.” We were told by the manager grab rails were not possible due to the poor design of the bathroom walls, which were supporting walls and not strong enough to safely support grab rails. The compliance manager showed us evidence following the inspection that the walls could support grab rails, but the provider had opted for toilet frames and shower chairs instead. They told us they would provide grab rails in showers if people requested them. The provider was looking into how this concern could be resolved but additionally safety measure for people at risk of falls had not yet been implemented in bathrooms.

The provider had systems in place to ensure staff were recruited safely. However, we found records did not all reflect this. All 3 staff records we reviewed had gaps in employment history and 1 staff member had no record of their ID or of it being checked. These were resolved retrospectively by the compliance manager.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff did not all have the knowledge required about people’s health to enable them to fulfil their roles. This included the manager who had significant gaps in their learning and ability to fulfil their role. People told us there was not enough staff to support them in a timely manner during busy times of day. One person said, “They could do with more (staff) as they rush around all over the place. It feels they’re a bit shorter at weekends.” Another person said, “There are no staff based in the dining room at breakfast and we can get taken there, then are left sitting for half an hour until someone has time to serve food and drinks.”

Managers did not always make sure staff received effective support, supervision and development. There was no evidence the managers were being supported in their roles by the provider to develop their skills and knowledge to be able to lead and manage the service effectively. Staff supervision occurred although staff told us this was often cancelled. Records showed a lack of effective supervision and appraisals, objectives were not set and staff knowledge and skills not always checked. The new manager had been trying to work with local health professionals to train the staff in safe management of a PEG for 1 person. A PEG is a Percutaneous endoscopic gastronomy tube that goes into a person's stomach to provide food, fluids and/or medicines when a person is unable to swallow these orally. This had proven difficult and while we were told training and competency checks had taken place, there was no evidence of this and meant there was no-one clinically qualified to retain clinical accountability and ensure the care of the person’s PEG remained safe. A professional told us, “Evidence of training matrix and upcoming training have required attention, they have now completed manual handling training and competencies, this is evident within their training matrix, however [evidence of] this has been requested to be sent over since the last visit and the documentation and has not yet been received, after reminding the home it is required.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. However, there was one area of the service we found had a very strong smell or urine that permeated throughout the corridor and surrounding bedrooms. Staff told us this was a known issue and a common occurrence at this area of the service. The manager told us they were aware but that the flooring did not need to be replaced and no effective action had been taken to resolve the issue.

We found there was enough personal protective equipment (PPE) such as disposable aprons and gloves. Staff told us they received training in IPC and regular audits of IPC were taking place. People and relatives felt the home was kept clean. A relative told us, “The home is clean. I do see staff hand washing. The bathroom is spotless. The room is tidy and well kept. I’m offered tea and biscuits. The place feels clean. It’s a new home.” A professional said, “IPC have attended and rated the home as good, there is an IPC audit in place to ensure that all standards are met and continued to be maintained.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The service had systems in place to safely store, administer and record the use of medicines. However, these were not always followed. We checked the quantities and stock balances for ten people, and we found them to be incorrect for nine of them. These medicines were being used to treat various conditions including, Parkinson’s disease, seizures and the prevention of blood clots. This meant that we could not be assured that the correct doses of medicines had been administered as signed for by staff. Not keeping accurate balances of medicines increases the risk of people suffering ill health.

The use of topical creams and ointments were recorded on the medicines administration records (MARs). However, body maps were not always in place to show staff the site of application. The date of opening had not been recorded on bottles containing medicines in liquid form. This meant that we could not be assured that these medicines were not being used beyond the manufacturers recommended period after the date of opening. Temperature records to ensure the safe storage of medicines were not completed in accordance with national guidance. This meant we could not be assured that medicines requiring refrigeration were safe for use.

People’s preferences of how they wanted their medicines to be administered were not recorded. Some relatives were concerned after they told us they had previously found tablets hidden in their family member’s bedroom, not taken. People told us staff did not always wait with them to be sure they had taken their medicines. A person said, “I can’t tell you what mine are for. I have 8 or 9 tablets. [Staff] will leave them and let me take them later and will pop back to check.” This meant managers could not be assured medicines were being administered as per prescribed instruction or that the correct person had taken them.

The service had individual fire risk assessments in place for people who were prescribed paraffin-based skin products. People were prescribed a medicine administered via a patch which needs rotating to different areas of the body, as recommended by the manufacturer. We found there was a process in place to indicate the site of the patch application. This prevents the patch being placed on the same site too frequently. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff.

Some residents were unable to take their medicines by mouth. Guidance was in place to enable staff to safely administer appropriately prescribed medicines into a stomach tube (Percutaneous endoscopic gastronomy, also known as PEG). There were appropriate arrangements in place for the management of controlled drugs (medicines that require extra checks and special storage arrangements because of the potential for abuse).

There was evidence that there was a process in place to record medicines related incidents or errors. Staff had completed a training and induction process for medicines management. Staff competencies were assessed regularly to make sure they had the necessary skills. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed. However, the shortfalls we found during the inspection had not been identified. The manager was not aware of STOMP and therefore people with a learning disability did not have STOMP plans in place to ensure medicines were regularly reviewed to make sure they were still appropriate. STOMP is an NHS initiative aiming at stopping the over medication of people with a learning disability, autism or both.

The managers have been working with professionals for guidance and support to improve processes for safe medicine management. A professional told us, “PRN protocols have been raised due to the lacking information around why they were given and what symptoms and behaviour changes to look for, prior to administration. The home management team have been open to advice around medication and absorbed all the information and implemented these changes quickly and efficiently.”