Archived: Fleetwood Lodge

Updated 23 November 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 3 and 11 October 2018 and was unannounced.

The inspection team included two inspectors and one Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert had experience of caring for older people who use services. They spoke with relatives and people living in the home. They also observed a lunchtime experience.

We reviewed information we held about the service, for example, statutory notifications. A notification is information about important events, which the provider is required to tell us about by law.

We reviewed records which included five people's care plans and medicines administration records as well as five staff recruitment and supervision records. We also looked at records relating to the management of the service such as the Home Development Plan, medicines audits, asbestos safety plan, resident meeting minutes, staff rotas, safeguarding minutes, accidents and incidents log, complaints and compliments records and the provider’s policies for safeguarding and medicines management.

After the inspection we reviewed further evidence sent to us by the provider which included pre-admission assessments, the staff training matrix and records of completed safeguarding investigations. We spoke with the manager, the deputy manager, the regional manager, eight relatives, three staff members and a visiting healthcare professional. We also spoke with eight people living in the home and observed people receiving care and support in communal areas.

Updated 23 November 2018

At our last inspection we rated the service Good with a rating of Requires Improvement in Well-Led. At this inspection we found the evidence continued to support the rating of Good and Well-Led had improved to good.

There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns.

This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At the last inspection, although the provider had made improvements to systems to monitor quality and safety within the service, sufficient time had not passed to ensure that these improvements were fully embedded to effectively monitor quality and safety in the service.

At this inspection we found the provider’s quality assurance systems had been developed and were effective in identifying service improvements. Audits were completed monthly and any identified actions were included in the home’s overall improvement plan, which contained dates for completion of identifiedactions. Evidence we reviewed showed actions had been completed within prescribed timescales.

The provider had taken prompt action in response to safeguarding concerns raised by healthcare professionals. The registered manager and staff had worked collaboratively with health and social care professionals to identify and address poor practice to ensure people received safe care.

People were protected from harm or abuse from appropriately trained staff who used the provider’s robust reporting systems. Risks to people were assessed and managed safely by appropriately trained staff.

People were supported to take part in their preferred activities and to have choice in their lives so that their independence was promoted and their freedom respected. Sufficient numbers of staff were deployed to meet people's needs and there were safe practices in place to ensure that people received medicines safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported according to their needs and preferences by appropriately trained staff. Care plans and risk assessments were regularly reviewed and updated and reflected people’s individual needs.

Staff liaised effectively with healthcare professionals to support people's health and wellbeing. People received consistent support from caring staff who knew them well and treated them with respect. Staff supported people to express their preferences about how they wished their care to be delivered.

The provider had a complaints policy in place and complaints were responded to and investigated promptly.

No-one at the home was receiving end of life care at the time of the inspection, however, people’s care and support documents contained information about what people wanted to happen in their last days.

The provider demonstrated an inclusive, to delivering care which was understood and shared by staff.

Further information is in the detailed findings below.