The Firefly Club Care Home

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

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

This service scored 56 (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 thoroughly investigate safety incidents, and lessons were not always learnt to continually identify and embed good practice.

Incident reporting had improved since the previous inspection, and we saw examples of staff identifying potential triggers and some learning being implemented after incidents. However, recording and follow up action was still inconsistent. For example, when staff recorded using ‘low-level physical guidance’, or described actions such as ‘staff responded immediately to manage the situation and ensure everyone’s safety’, there was no evidence further information was sought as part of the incident review process. Although debriefs took place after some incidents, this was not always consistent. A lack of information about actions taken in response to incidents limited the provider’s ability to review the actions taken and identify learning.

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 improved their pre-assessment process since our last inspection. This meant people’s transitions into the service would be managed and monitored more effectively. We received feedback from professionals that the service made appropriate referrals when required, in a timely manner. Hospital passports for people were in the process of being developed.

The provider shared concerns appropriately and had processes to identify and report safeguarding concerns. Staff we spoke with gave examples of types of abuse and told us how they would report potential safeguarding concerns. Safeguarding notifications were submitted when required. The provider made Deprivation of Liberty Safeguards (DoLS) applications as required when people were deprived of their liberty.

The provider sometimes worked well with people to manage risks, but risks to people were not always assessed and mitigated. For example, there was no clear care plan, risk assessment or guidance for staff to monitor a person who had recurrent wounds on their foot. However, other risks to people were assessed and actions taken to reduce the risk of harm, for example, in relation to epilepsy. When people communicated distress or agitation in a way that could pose a risk to themselves or others, staff told us how they supported people in a positive manner. Although staff we spoke with knew people well and could tell us how they supported people, inconsistencies with the quality of records meant we could not be assured actions taken to reduce risk would always be consistent or accurate. The provider was aware of shortfalls remaining in this area and was working hard to make the required improvements.

The provider did not always detect and control potential risks in the care environment.

A fire door inspection in October 2025 identified most fire doors had gaps that were not within safe limits to ensure they would be effective in case of fire. The shortfalls were not identified in the providers own auditing processes before this. Remedial works were booked for June 2026.

The general environment in the service was not homely; there was little decoration and most walls were bare. We discussed this with the registered manager who told us their plans to improve this, involving people and ensuring the environment was reflective of their personal preferences.

The provider did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide care that met people’s individual needs. Staff received training around supporting people with a learning disability and autistic people, at a level appropriate to their role. We received feedback from relatives and staff that people were not always able to be supported with the support hours they were allocated to receive. At the time of our inspection, the provider was in the process of introducing a dependency tool to monitor staffing levels and ensure people received the right level of support. The provider used a colour coding system on the rota to ensure there was always a staff member trained to administer medicines on shift.

The provider followed robust recruitment processes to ensure staff were recruited safely, in line with legal requirements.

The provider did not always assess or manage the risk of infection.

Areas of the home were not always clean, or able to be effectively cleaned due to damage, for example, people’s bedroom floors. Care staff were responsible for managing all cleaning tasks. However, they did not receive specific training in this area and did not always have time to fulfil these. Following initial feedback during our site visits, 3 people’s bedroom floors were replaced, and the provider introduced a housekeeping member of staff to undertake some tasks. We observed staff using personal protective equipment (PPE) such as gloves when required.

Medicines were not always managed safely.

Medicines audits were completed and staff we spoke with told us actions they would take if they made a medicines error. However, some medicines errors were not identified in audits. For example, 1 person’s prescribed cream was recorded as out of stock from 07 April 2026. However, a staff member had signed the medicines administration record stating they had applied the cream on 4 occasions while the cream was out of stock. This meant we could not be assured medicines records were always accurate. We raised this with the provider who acted in line with their medicines policies and procedures.

When medicines were prescribed ‘when required’ (PRN) or with variable doses, protocols were not always in place to guide staff on when or what dose to administer the medicine. When PRN protocols were completed, they sometimes lacked detail.

Relatives told us, and records showed, that medicines were reviewed and discussed as appropriate. This was in line with the Stopping over medication of people with a learning disability and autistic people (STOMP) principles.