Fleetwood Heights

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 newly registered 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 the management of people’s medicines. 

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents, incidents and falls were recorded on the electronic care system and were generally well completed. However, the time the event had occurred was not always recorded and some incidents were entered twice by different staff members. The provider had already identified these anomalies and was taking action to address them.

Accidents, incidents and falls were monitored and reviewed monthly, analysing trends and themes. Where actions had been identified, these had been completed. For example, following 1 person’s fall sensor equipment was put in place and discussions were held with the person and their relatives about moving the position of their bed. Lessons learned were shared with staff to keep people safe and embed good practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had robust processes in place to ensure people’s needs could be met by the service prior to admission. The manager completed pre-admission assessments with people and their appointed representatives. This information was then reviewed and verified by the senior management team to ensure safe admission processes and continuity of care.

Records showed, where people required support from other health and social care professionals, appropriate referrals were made in a timely manner.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe, and relatives also felt their family members were safe. Safeguarding procedures were available to people, relatives and staff. Staff were up to date with training and knew how to report any allegations of abuse. Records showed safeguarding incidents had been reported, referred to the local authority and notified to the Care Quality Commission (CQC).

Staff had received training in the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). The provider maintained a DoLS tracker and kept accurate records of applications and their progress. Only 1 person had a DoLS authorisation in place. Care records showed the condition on the DoLS authorisation was being met.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People told us they felt safe and well supported. Individual risk assessments were in place and regularly reviewed.

Staff understood people’s individual risks and how to support them effectively. We saw all the necessary equipment was in place to mitigate risks to individuals and help keep them safe. Staff followed safe working practices that promoted people’s well-being while encouraging independence where possible.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

At the time of our assessment only the ground floor of the service was occupied. However, safety certificates were in place for the whole building and regular maintenance checks were undertaken throughout the property.

The ground floor was well maintained, decorated and furnished to a high standard. People said the maintenance staff member was very responsive and quick in addressing any issues. One person commented, “Nothing appears to be too much trouble for [maintenance staff].”

Bedrooms had ensuite facilities and were personalised to reflect individual preferences. There were a variety of communal areas all offering a spacious, bright and accessible setting for people to enjoy. People also had access to a secure garden area.

The environment was dementia-friendly with good lighting, clear signage and colour schemes to enable people.  

The provider did not always make sure there were enough qualified, skilled and experienced staff to meet people’s needs. Staff did not always work together well to provide safe care that met people’s individual needs.

We received mixed feedback from people about staffing levels. Most people felt there were enough staff, however, 2 people said they didn’t like having to wait to get up, washed and dressed in the morning. One person said, “It was 11.30am before I got up today. I had to have my breakfast in bed, and I don’t like that.”

Staff told us there were generally enough staff to meet people’s needs. However, some staff said there needed to be more consistency amongst the nurses in relation to the organisation of the shift and allocation of staff.

The provider used a dependency tool to calculate safe staffing levels according to people’s needs. Rotas showed a mix of skills and experience across shifts.

Staff were trained and competent in their roles. A training matrix was in place to monitor compliance, and staff received regular supervisions and appraisals to support their development and maintain good practice.

Recruitment processes were safe. All required pre-employment checks were completed, including references and Disclosure and Barring Service (DBS) checks.

The provider had also taken proactive steps to support future admissions by beginning to recruit additional staff.

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.

People and relatives praised the domestic staff for maintaining high standards of cleanliness. The environment was clean, well maintained, and free from unpleasant odours.

Staff had completed training in infection prevention and control. During our site visits, we observed staff using personal protective equipment (PPE) appropriately and practising good hand hygiene.

The provider carried out regular audits to monitor cleanliness and infection control practices and ensured any improvements were implemented.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were not always administered as prescribed. We found records showed some people had not always received the correct dose of medicines.

Instructions for medicines given when required (PRN) were available however they did not always contain person-centred information. The home had been made aware of this via an audit and had begun work to review these protocols.

We found medicines prescribed to be administered at specific times were not always administered as instructed. For 3 people who required a four-hour gap between doses, this interval was not consistently maintained, resulting in some doses being given too close together.

For people prescribed medicine patches there was not always a record of where this was applied on the body, and we could not be assured staff had always followed the manufacturer’s instructions on rotating the location of the patch.

People’s medicine records contained information on allergies. Applications of topical preparations such as creams were documented on medicine records. Medicines were managed by staff who had been trained and had their competency assessed.

The provider was responsive to feedback from the assessment and had already started making improvements in the areas identified.