Archived: Fitzwilliam Care Centre

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 requires improvement. 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 consent.

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’s needs were assessed prior to admission but information was not always accurate when transferred to care plans.

Some people had past and recent histories of substance misuse and had experienced significant health difficulties and, or risk behaviours as a result. Care plans did not include how to support them with these issues, what staff should be aware of and whether there was a risk posed to other people in the service if alcohol or illicit substances were brought into the home.

People had a variety of complex mental health and physical needs, however care plans contained limited or no reference of input from external health and social care professionals.

A professional told us, “Our clinical team has found that [people with] complex mental health often had gaps in past medical history and a lack of information regarding handovers (or a complete lack of handover) to a local mental health team. Many of the residents have a dual diagnosis and require the ongoing input of specialist mental health services and a detailed history is therefore essential to be able to provide safe and appropriate care. This is of particular concern when patients have been transferred without sufficient medication and urgent prescriptions have been requested.”

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. People’s care plans had numerous links to articles about health conditions but did not reference how these were relevant to the needs of the individual receiving care. Some people with the same diagnosis such as heart conditions have very different needs and these were not identified in the care plan.

Another person who was diagnosed with seizures due to alcohol use had multiple links to articles on the subject of seizures and alcohol in their care plan. However, these were not helpful for staff who needed to know what they needed to look for in terms of this individual person and how to mitigate and manage the risks they presented with. The articles were not best practice resources from recognised institutions such as National Institute for Health and Care Excellence and were sometimes based on American practices. It would be difficult for staff to have time to read the articles and apply the content to the people in their care.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services. The management team were working with various partners to review improvements being made at the service. However, professionals we spoke with all had concerns about transparency and timeliness of sharing records or other information that had been requested. They continued to have concerns about poor care notes, medicines not being administered as prescribed, best interests process being followed for decision making, call bells not in place, people’s finances, incident management and falls management. This meant they did not always have the information they required to have a full understanding of a person’s presenting needs or new risks.

A professional told us, “We are still yet to receive responses from the manager regarding our concerns and actions we requested were taken. I have chased again. It is not uncommon for us to have to chase the managementteam over several weeks to get responses and even then these are often not directly responding to specific concerns/actions we have raised.”

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support. People’s health outcomes were recorded such as visiting from health professionals and health statistics for example, weight, pulse and temperature. However, daily notes lacked context or evidence of person-centred approaches so care lacked a holistic approach.

People identified as having a risk of malnutrition and assessments indicating they required additional treatment and support, did not have robust interventions in place in line with best practice guidance. Care plans indicated that decline in nutritional intake was a key factor in declining mental health, but there were no instructions to staff on how to monitor this. Staff care records recorded very little information about nutritional intake and how to escalate concerns, on some occasions it appeared for 1 person, no food had been taken for over a day.

People also had concerns about meal options. A person told us, “The fridge and the cupboard is empty, we have a big meal at lunch time and breakfast. Later on, it’s just sandwiches so not a proper meal. [Staff] are supposed to be doing a thing called Appetito but it's not here yet. I feel it would be good to turn it around to have maybe sandwiches or a snack at lunchtime and a proper meal at evening time. I have no involvement in choosing the meals, [staff] just give us what we get.” Appetito is a company providing ready-made meals for people delivered to their home.

Staff knew to contact external health professionals for advice but contact details for the various professionals with the exception of the GP was not available in care plans for them to easily do so.

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. A relative told us, “When my [family member] initially went into Fitzwilliam things weren’t too bad. When I visited, I noticed a difference in the level of personal care. I asked a few questions and was told that [my family member] was OK. They didn’t get up until 11 or 12, but the impression I got was that they were 1 less person to deal with. When I visited in August you could tell they hadn’t been showered, and when I asked how often it happens I didn’t get a straight answer. [My family member] still recognises me and the first thing they said [when I visited], was ‘get me out of here’.”

The provider lacked systems to monitor the accuracy of care records and address when care had not been delivered or recorded. The provider had not identified that in many cases care plans lacked information other than a description of the problem. There was often no outcomes or care actions recorded.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment. Peoples’ mental capacity was not always recorded within assessments. Most people’s daily care records and subsequent care plans indicated that people had capacity to make decisions about their care. However, in all care plans reviewed, without exception, where care plans asked if people had been involved in discussing care and risk, this had been ticked no.

Staff had a mixed knowledge of consent and how to promote choice. They struggled with knowledge of how to recognise concerns or deterioration of people’s health conditions in particular mental health.