Archived: Fallodon Way

Updated 5 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Fallodon Way is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Fallodon Way is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since March 2021 when the provider took over the service. We used all this information to plan our inspection.

During the inspection

We spoke with three people who used the service about their experience of the care provided and spent time with others observing interactions with staff. We spoke with eight members of staff including the registered manager, the team leader, care staff, a compliance co-ordinator and the area manager. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included three people's care records, daily records for everyone using the service and a number of medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We emailed three health and social care professionals for their views on the service, but we did not receive a response.

Updated 5 May 2022

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

Fallodon Way is a care home providing personal care to ten people with a learning disability. At the time of our inspection there were eight people using the service.

People’s experience of using this service and what we found

The service was able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. The new provider had an action plan which was making improvements to the service including involvement of people and the planning of care in particular activities.

Right Support

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, improvements were needed to activity planning to ensure that people could pursue their interests in a more meaningful way.

Staff promoted equality and diversity in their support for people. They understood people's cultural needs and viewed people as individuals. People had care that supported choice in how they wanted to live. People’s routines were promoted, supported and captured in their care plan and how the staff supported them.

People’s care was planned with them. Fallodon Way provided a homely atmosphere for people. Improvements were being made by the new provider to the general décor of the home. Some works had been completed, such as redecoration of the communal areas of the home. Plans were in place for this to extend to people’s bedrooms and personal space. People had personalised their bedrooms with personal affects, but rooms were looking dated.

Some safety aspects had not been identified and mitigated prior to the inspection. The risk to people from hot, uncovered radiators had only been addressed in response to our findings. There were significant gaps in the recording of daily cleaning, water and fridge temperatures, which potentially could put people at risk of harm. Whilst the provider’s audits had identified these concerns, action had not been taken promptly to mitigate any risks.

Right Care

People's healthcare needs were being met. Other health and social care professionals were involved in the care and support of people. People were supported with healthy eating and received effective support in relation to monitoring their healthcare. People were supported to receive their medicines safely.

People received care from staff that had been through a thorough recruitment process. Staff were caring in their approach towards people. Staff knew what they had to do to keep people safe and knew what to do if they were concerned. Staff had received training in safeguarding adults and were confident that if they had concerns these would be acted upon.

New staff had received a comprehensive induction. There was a training plan in place for all staff which was being monitored. Staff confirmed they had received ongoing training since the changeover to the new provider.

Right culture

There had been a change of provider and some of their values and ethos were still being implemented to ensure there was a positive culture within the team. A team building day was taking place to develop the team. In addition, further staff training was being arranged such as positive behaviour support and mental capacity, which would enhance the skills of the staff and improve how people were being supported and engaged.

Relatives were happy with the care and support that was in place, although they recognised improvements were needed in supporting people with meaningful activities. They understood the pandemic had stopped some external activities taking place. They were positive about the communication they received.

The provider had systems to monitor the quality of the service. However, some of the concerns we had found had not been picked up by the provider’s assurance processes or completed in a timely manner such as the gaps in recording. This included records relating to safety such as water temperatures, fridge temperatures and those records relating to capturing people’s experience in meaningful activities and occupation.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for the service under the previous provider was good, published on 20 March 2020. The service has now been rated requires improvement.

Why we inspected

This was a planned inspection due to a change of provider. We undertook this inspection to assess that the service is applying the principles of Right support right care right culture.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Fallodon Way on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to relation to the governance arrangements of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.