CQC report explained · a residential care home
What the CQC found at Fleetwood House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and support plans were not always clear, current or completed properly. Staffing shortages sometimes meant people could not go out, and guidance for some as-needed medicines was unclear.
- Effective?
- Requires improvement
- Some therapy support had not happened as recommended, and healthcare records were not always accurate or up to date. Staff training and food support were positive.
- Caring?
- Good
- Staff were kind, respectful and understood people's individual communication, routines, interests and support needs.
- Responsive?
- Good
- Care plans recorded people's preferences and communication needs. Staff supported relationships, visits, religious needs and activities, although staffing sometimes limited community activities.
- Well-led?
- Requires improvement
- Management oversight did not consistently identify or address gaps in records and risk monitoring. Some required notifications were not sent to the CQC at the time.
What inspectors found, April 2022
Fleetwood House rated Requires Improvement; inspectors found kind, respectful care but gaps in risk records, staffing and management checks.
Inspectors visited on 13 and 14 January 2022 without announcing the visit. They observed care, spoke with relatives, an advocate and staff, and reviewed care, medicine, recruitment and management records.
People were generally treated kindly and respectfully. Staff knew people well, supported their communication and offered personalised food, activities and living spaces. Infection control, medicine storage and recruitment checks were managed safely.
However, staffing shortages sometimes limited outings and one-to-one activities. Some risk assessments, therapy plans, medicine guidance and daily records were incomplete or out of date. Management checks had not found these problems, and the home did not always notify the CQC about safeguarding and liberty protection events.
The overall rating was Requires Improvement. Caring and Responsive were rated Good. Safe, Effective and Well-led were rated Requires Improvement. The CQC identified breaches of Regulations 12 and 17 and requested an action plan.
Kind and respectful care
Inspectors saw calm, caring interactions. Relatives said staff treated people with dignity and knew them well.
“Staff treated people with kindness and spoke in a friendly and caring way.” from the report
Individual communication
Staff adapted how they communicated, using speech, gestures, body language, visual cues and objects of reference to suit each person.
“Staff adapted their verbal language, body language and gestures to people's individual needs.” from the report
Food and mealtimes
People helped choose meals, which were prepared from fresh ingredients. Mealtimes were calm and dietary needs were followed.
“We observed mealtimes which were calm and well organised.” from the report
Staff development
Staff had structured induction, training and supervision. They said managers were supportive and helped them understand people's needs.
“The twelve week induction included a range of learning opportunities such as shadowing and working with experienced staff and understanding people's needs.” from the report
Welcoming environment
Bedrooms and communal areas reflected people's interests and choices. The garden was accessible, and a separate garden room supported visits and sensory activities.
“People's rooms were decorated to reflect their interests, preferred colour scheme and décor they found attractive.” from the report
Staffing affected outings
needs fixingThere were regular staffing shortfalls. Care in the home was provided, but outings and some one-to-one activities were delayed or missed.
“There were not always enough staff to ensure people were supported to go out.” from the report
Therapy and health records
seriousRecommended speech therapy and physiotherapy exercises had not always taken place. Some personalised healthcare guidance had not been reviewed for more than four years.
“Personalised healthcare guidance, such as therapy plans, had not been reviewed for over four years.” from the report
Weak management checks
seriousAudits had not found gaps in health monitoring, therapy plans or as-needed medicine guidance. Incident records did not always explain how risks were addressed.
“Management audits and checks had not identified the gaps in constipation monitoring records, therapy plans or guidance for 'as required' medicine.” from the report
Some notifications were late
seriousSafeguarding and deprivation of liberty events had not been notified to the CQC when they occurred. Notifications were sent after inspectors raised this.
“During our inspection we found there had been safeguarding and deprivation of liberty events which were not notified to the Care Quality Commission.” from the report
Unclear as-needed medicine guidance
needs fixingSome instructions and records for medicines used when required were not clear, including medicines linked to seizures and breathing difficulties.
“Some guidance to staff and records for medicines which people needed 'when required', also known as PRN medicine, were not always clear.” from the report
- 01What has been done to ensure every person has an up-to-date risk assessment and clear support plan, including for self-harm or crisis situations?
- 02How will you make sure there are enough staff for outings, community activities and one-to-one time?
- 03Have all speech therapy, physiotherapy and other health plans been reviewed and delivered as recommended?
- 04What new checks are in place to make sure care records, bowel charts, body maps and medicine guidance are accurate and complete?
- 05Have all safeguarding and deprivation of liberty notifications now been reviewed and sent to the CQC when required?
This was the first planned inspection under the new provider and covered all five key questions, including infection prevention and control and COVID-19 vaccination requirements. This explanation was written from the published report of 7 April 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Fleetwood House
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020
Registered with the Care Quality Commission on 21 September 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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28 live-in carers within about an hour of West Sussex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.