Fleetwood Hall

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 meant people were safe and protected from avoidable harm.

This service scored 66 (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.

Processes were in place to ensure safety incidents were appropriately investigated and reported, and outcomes shared with the team. Staff had good knowledge about how to identify and escalate concerns and report these appropriately. They told us incidents were discussed in handover meetings as opportunities for 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.

Before moving into Fleetwood Hall, a pre-admission assessment was carried out to ensure the service could meet people’s needs. The management team effectively shared information when people were admitted to hospital or required care at home after leaving the service.

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.

As part of this assessment, we asked if people felt safe living at Fleetwood Hall. One person told us, “Yes, I do feel safe – I have never thought about it.” A second person commented, “Yes I do feel very safe.” One relative said, “[Family member] is very safe, you have people on hand if you need them”.

The provider investigated safeguarding incidents and shared concerns quickly and appropriately with the relevant authorities. Staff had received safeguarding training and knew how to identify and report abuse. One staff member commented, “People are safe, they know the staff and we know them. I would also report any concerns to management.”

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.

People were supported to manage risks in ways that respected their choices and enabled them to lead fulfilling lives. However, some care plans did not provide sufficient guidance on how risks should be managed to keep people and staff safe. This included records relating to times when people became distressed. Staff were able to clearly describe how they supported people and managed risks effectively. Following our feedback, the management team reviewed the relevant records and took prompt action to address the identified concerns.

When people required thickened fluids to support safe swallowing, the provider had not got a process for timing how long thickened drinks had been prepared. Following feedback, the provider acted promptly to address the issue and implemented safeguards to ensure people received their prescribed drinks safely in line with best practice.

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

There was a fire risk assessment, and regular fire drills took place to help manage the risks around fire, ensuring staff had good knowledge of fire safety procedures. Every person had a personal emergency evacuation plan (PEEP). The purpose of a PEEP is to ensure that all people can evacuate the building safely and promptly in the event of an emergency, regardless of their level of mobility or other health conditions.

Equipment was available and maintained to meet people’s needs. We saw evidence fire equipment, lifting equipment and electrical safety checks were completed as required by regulations such as Lifting Operations and Lifting Equipment Regulations 1998 (LOLER).

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

We received mixed feedback from people on suitable staffing levels. One person told us, “I have pressed it [call bell] once and it took them about 25 minutes, but it was getting up time.” A second person commented, “Not long, especially at night they can be here more or less straight away because they know I need them if I call.” A relative said, “It does depend on what they are doing.” A second relative commented, “It is debateable, personally I think they need more staff because at certain times it can be hectic and weekends can be worse.” The provider was in the process of purchasing a new call bell system, which would allow management to monitor call response times. This would identify trends, highlight any delays in responding to people’s requests for assistance, and allow management to take timely action where improvements were needed.

We discussed staffing levels with the deputy manager who stated they used a staff dependency tool to work out how many staff are required within the home. A staff dependency tool is a system used to measure the specific care and support needs of individuals (such as residents in a care home or patients in a hospital) and convert those needs into the exact number of staff, hours, and skill mix required to care for them safely.

The provider followed recruitment procedures to ensure all required checks were completed before staff started work at the service. Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

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.

Personal protective equipment (PPE) was available throughout the home, and staff were observed using this appropriately to reduce the risk of infection. Housekeeping staff worked effectively to maintain cleanliness across the service.

However, some areas of the home required refurbishment to support effective cleaning and maintenance. For example, some bedroom ensuite doors were damaged, which made them more difficult to clean. The provider had identified these issues through their own monitoring processes and had plans in place to replace the affected doors. One person told us, “They [bedrooms] are very clean and comfortable, and the beds are changed regularly.”

Fleetwood Hall had a food hygiene rating of 5 (out of 5). This meant hygiene standards were very good.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider had systems in place for the safe storage, administration, and monitoring of medicines, thickeners, and topical creams. Since our last inspection, the service had introduced an Electronic Medication Administration Record system, strengthening the administration, recording, auditing, and oversight of medicines.

People told us they received their medicines as prescribed and had regular medication reviews to ensure their medicines remained appropriate and effective. One person told us, “I have [health condition] so I need my tablets at the same time morning and night. I also take paracetamol when I need to; they [staff] check what you have taken so you can’t overdo it.”