About the service Fullwood House is a residential care home providing accommodation for nursing or personal care for people with mental health conditions. At the time of inspection, they were also providing a service to people with a learning disability although they had not updated CQC about this. At the time of our inspection the service supported ten adults in one adapted building.
People’s experience of using this service and what we found
The systems in place to assess, monitor and manage risks to people's health, safety and welfare were unsafe.
People were at risk of harm because government guidance for infection prevention and control processes were not being followed.
Risk assessments were not always in place for specific risks to people. People were not always involved in the process to assess, develop and review risks and their support plans.
People received their medicines as prescribed. However, ‘as and when required’ medicine, PRN administration guidance for staff lacked in person centred detail and medicines were not always stored where the temperature was being monitored.
People’s communication needs were not always identified.
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.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
The service was not able to demonstrate how they were the underpinning principles of Right support, right care, right culture.
People told us they wanted to move on from the service but had not been given the support to do so. This demonstrated that people are not provided with the support they need and want to maximise their choice, control and independence.
Care plans did not demonstrate person-centred care. This means people are not involved in all decisions about their lives. Care was not always person-centred.
People were cared for, but they weren’t empowered to lead confident inclusive lives.
The management of the service did not always have oversight of the risks identified above. This put people at risk of harm.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 19 July 2019).
Why we inspected
This was a planned inspection based on the previous rating.
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.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.
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 Fullwood House on our website at www.cqc.org.uk.
Enforcement
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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We identified breaches in relation to safe care and treatment, person-centred care and governance at this inspection. The provider told us they have taken action to mitigate some of the risks. For example, face coverings are now being worn by all staff, window restrictors have been put in place and risk assessments for self-harm have been put in place. Where improvements had been made these needed to become fully embedded.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.