Serious CQC criticism of Southport’s ‘Inadequate’ Fleetwood Hall

10th May 2016

Photo: Fleetwood Hall

Serious CQC criticism of Southport’s ‘Inadequate’ Fleetwood Hall

This unannounced inspection of Fleetwood Hall care home took place on 9, 10 & 23 March 2016.

The home was inspected in January 2015 and judged as ‘inadequate’ overall. We identified eight breaches of the regulations. The provider (owner) agreed not to admit any people to the home while the breaches in regulation were being addressed. We inspected the home again in July 2015 and judged it as ‘Requires improvement’ overall. While significant improvements had been made since the inspection in January 2015, we did not revise the ratings for each domain above ‘Requires improvement’. To improve a rating to ‘Good’ would have required a longer term track record of consistent good practice. However, we did identify one breach of the regulations.


Is the service safe?

The service was not safe.

Medicines were not managed in a safe way. Discrepancies with the management of medicines were not being identified on routine audits.

Staffing levels were inadequate to ensure the risk presented by some people was managed effectively, and to ensure the safety of other people living at the home.
Few staff were aware of what constituted an adult safeguarding concern. More than half the staff team required training in adult safeguarding. Not all incidents had been appropriately safeguarded in accordance with local procedures.

Effective arrangements for the recruitment of staff were in place.

Some areas of environment were not safe. Fire doors had been wedged open on the mental health unit. Parts of the corridor floor were moving creating a risk to people with limited mobility.


Is the service effective?

The service was not effective.
Staff training, supervision and appraisal was not up-to-date.

People were satisfied with the food and said they were happy with the choice at mealtimes.

The principles of the Mental Capacity Act (2005) were not being adhered to when assessing people’s capacity with specific decision making. Staff were clear about how many people had lawful restrictions in place to deprive them of their liberty.

People told us they had access to health care services when they needed it.


Is the service caring?

The service was not caring.

On the mental health unit men there was not a dedicated female lounge or specific toilets/bathrooms for women.

The service was not caring.

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On the mental health unit men there was not a dedicated female lounge or specific toilets/bathrooms for women.

Staff were mostly caring, respectful and kind in the way they engaged with people. We did observe a small number of occasions were this caring approach was not sustained.

People’s personal histories, background and preferred routines were either not recorded or poorly completed for some people.

People and/or their families were not involved in on-going reviews of their care plans.


Is the service responsive?

The service was not responsive.

People consistently told us they were bored and that there was not much to do each day. People said they did not have a specific social/recreational plan based around their specific interests and preferences.

A complaints procedure and process was in place. It was not effective as management were not clear about how many complaints had been received. A complaint received in February 2016 had not been acknowledged.


Is the service well-led?

The service was not well-led.
The manager had been registered on 1 February 2016.

There had been a number of management changes in recent years and staff told us this was unsettling.

Systems to monitor the quality and safety of the service were not robust. These included checks and audits, feedback systems and the incident reporting and analysis system.

The registered manager acknowledged that there were shortcomings with the service, particularly in relation to staff culture and out-dated practice. The registered manager and provider had already started to address these issues. However, it was too early to see the impact these changes were having in ‘turning the service around’.

Read the full report here


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