Fitzwilliam Lodge

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 remained good.

This service scored 75 (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, concerns and near misses were recorded, reviewed and analysed to identify themes and opportunities for improvement. Learning was used to improve support and reduce risks. For example, support was reviewed following seizure activity and changes in behaviour linked to physical health concerns. Care plans, risk assessments and staff guidance were updated when learning identified opportunities to improve people's safety and wellbeing.

This helped ensure learning was translated into action and support adapted as people's needs and circumstances changed.

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.

Information was shared effectively when people moved between services, helping staff understand their needs and continue supporting their recovery. This helped ensure people received the right support at the right time. For example, hospital information packs were generated from the electronic care planning system and used to pass information between providers. This process helped ensure people’s needs were communicated clearly supporting continuity and consistency of care

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. Staff were knowledgeable about safeguarding procedures and knew how to recognise and report abuse. A staff member said, "I would report abuse immediately. I am very confident that actions would be taken. If I felt that nothing had been done, I would contact the local safeguarding team." Relatives told us they felt their loved ones were safe.

The principles of the Mental Capacity Act 2005 (MCA) were understood by the registered manager and there were processes in place to review people’s capacity in line with the MCA. The 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 Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

We found the service was working within the principles of the MCA. People had care plans in place to ensure DoLS were recorded and people were supported in line with them. Where people lacked capacity, best interest decisions had been completed to ensure their views, wishes and preferences were considered.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks associated with people's care were identified, assessed and managed to help keep people safe. Staff worked with people and relevant professionals to consider risks and agree appropriate measures to reduce them. Positive risk-taking was encouraged where this supported people's independence and wellbeing. One professional told us, “Staff pass on concerns and risks appropriately and manage a great deal of challenging behaviour and complex mental and physical health conditions associated with risks."

Staff supported people to balance safety with independence and ensured restrictive approaches were only used when necessary. They worked with external professionals to help people access the support they needed and respond to changing risks.

This approach supported people to make progress towards their goals and achieve positive outcomes. For example, some people developed the confidence to access their local community, while others built skills to manage their medicines more independently and develop social connections. People told us these achievements made them feel "proud, happy and normal."

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular safety checks were completed in line with expected standards. Personal emergency evacuation plans (PEEPs) were in place to help people leave the building safely in an emergency.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Staff received training and support which gave them the skills, knowledge and confidence to carry out their role’s effectives. One staff member told us, "We receive all training face to face or eLearning. I feel I have the right support.”

Staff spoke positively about staffing levels. One staff member told us, "I feel staff and I have enough time to carry out our job role and we have sufficient staff.” Professionals confirmed this and recognised the positive impact consistency had on people. One told us, "There's not a really high turnover of staff, which makes a difference. [Person] benefits from this. [Person] doesn't cope well with staff turnover, so it benefits them." Another said, "I've never had a problem getting hold of [staff] when I need them. They're very responsive."

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 lived in an environment where cleanliness and infection prevention were appropriately managed, helping to reduce the risk of infection and maintain their wellbeing.

The service was clean and staff followed appropriate infection prevention and control procedures. Staff used personal protective equipment (PPE) where required and infection prevention measures formed part of everyday practice.

Regular audits and external monitoring were completed to provide oversight of infection prevention arrangements. Where improvements were identified, action plans were developed and monitored.

The provider made sure medicines and treatments were safe and met people's needs, capacities and preferences. People received their medicines safely and in a way that reflected their individual needs and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored securely and records relating to the administration of medicines were completed appropriately. Staff received training and competency assessments before supporting people with their medicines.

Medicine support was personalised and included information about people's preferences, allergies and the use of medicines prescribed on an ‘as and when’ required basis. People were supported to self-administer their medicines where this had been assessed as safe and appropriate.

The service had systems to monitor medicine stock levels, manage returns and respond to medicine errors. People were involved in decisions about their medicines and support was provided in ways that promoted safety and independence.