CQC report explained · a residential care home
What the CQC found at Fullwood House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm through risk assessments, detailed care guidance, safe medicine systems and suitable staffing. Infection prevention arrangements, recruitment checks and emergency evacuation plans were also in place.
- Effective?
- Requires improvement
- This key question was not covered in this focused inspection. Its rating was therefore carried forward from the previous inspection.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were involved in care planning and day-to-day choices, and were encouraged to develop their independence.
- Responsive?
- Good
- Care plans recorded people's needs, preferences and communication methods. People were supported with local outings, holidays, relationships, household tasks and interests.
- Well-led?
- Good
- The home had regular audits, action plans and reviews of accidents and incidents. Staff meetings, accessible information and monthly house meetings supported communication and people's involvement.
What inspectors found, May 2022
Fullwood House was rated Good; inspectors found safe, kind and person-centred care, with clear improvements since the previous inspection.
This was an unannounced focused inspection on 20 April 2022. One inspector spoke with four people using the home, one relative and staff. They reviewed care records, medicine records, recruitment files and management documents.
Inspectors found that people were safe, treated kindly and involved in decisions about their care. Staff knew people well. Care plans gave detailed guidance, medicines were managed safely, and people were supported with activities, relationships and independence.
The home had improved since its previous inspection, which was rated Requires Improvement and found breaches of regulations. Inspectors said the provider had completed its action plan and was no longer in breach of those regulations.
The overall rating is Good. However, this was a focused inspection, so some ratings were carried forward from the previous inspection rather than reassessed during this visit.
Detailed risk planning
People's health needs and risks were recorded clearly, with guidance for staff on how to support them safely. Environmental risks and emergency evacuation information were also reviewed.
“People's care plans contained detailed guidance for staff to follow to meet a person's needs consistently.” from the report
Safe medicines
People received medicines as prescribed. Staff recorded when as-required medicines were given and checked whether they had worked.
“People received their medicines safely as prescribed.” from the report
Kind and respectful care
Inspectors saw positive interactions between staff and people. People were involved in care planning and supported to make their own decisions.
“We observed positive interactions between people and staff who knew them well” from the report
Choice and independence
People took part in activities at home and in the local community. They were supported with tasks such as laundry, cleaning, gardening and making drinks.
“People were supported to participate in activities outside the home.” from the report
Improved oversight
The manager and provider used audits and action plans to monitor care, medicines, infection control and environmental risks. This addressed the governance concerns found previously.
“Quality audits were carried out by the provider monthly to ensure the audits and action plans completed by the registered manager were effective” from the report
Inspectors raised no specific concerns in this report.
- 01How are the improvements made after the previous inspection being checked and maintained now?
- 02How would staff support my relative's specific health conditions and changes in their condition?
- 03How would my relative be supported to make choices, communicate preferences and develop independence?
- 04What activities and community outings would be available for my relative, and how would staffing support them?
- 05How are medicines, including as-required medicines, reviewed and monitored for my relative?
This was an unannounced focused inspection of Safe, Caring, Responsive and Well-led; the report says the other ratings used to calculate the overall rating were carried forward from the previous inspection. This explanation was written from the published report of 18 May 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.
What inspectors found, November 2021
Requires Improvement; inspectors found risks in medicines, infection control, care planning and management oversight.
This was an unannounced inspection on 22 and 28 September 2021. Inspectors spoke with people, relatives, staff, the manager and a visiting professional. They reviewed care records, medicine records, staff files and management records.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were at risk because infection control, risk assessments, medicines, staffing checks, training and care planning were not reliable enough.
There were also some positive findings. Staff knew how to report safeguarding concerns, people said staff were kind, staff respected privacy and dignity, and people spoke positively about the food. The overall rating had fallen from Good at the previous inspection, published in July 2019.
Safeguarding awareness
Staff understood how to report safeguarding concerns, including to outside agencies. They had received safeguarding training.
“Staff spoken with were knowledgeable about how to raise a safeguarding concern, which included informing the management team and outside agencies, such as the Care Quality Commission (CQC) and the local authority.” from the report
Food
People gave positive feedback about the food. Records were kept when there were concerns about someone's food or fluid intake.
“People told us the food was really good.” from the report
Infection control
seriousStaff were not consistently following government guidance on masks and clothing. The home was not thoroughly clean and there was not enough hand sanitiser.
“We were not assured that the provider was keeping people safe from COVID-19 transmission.” from the report
Medicines
seriousThere were problems with medicine guidance, records, competency checks, storage temperatures and disposal. These issues could lead to people receiving medicines incorrectly.
“Medicine which could be given 'as and when required' was not always safely managed.” from the report
Risk assessments
seriousSome risks, including self-harm, windows and emergency evacuation, were not properly assessed or recorded. This left people at risk of harm.
“People's mental ill health, put them at risk of harming themselves.” from the report
Person-centred care
seriousCare plans did not contain enough individual information. Three care plans were largely the same, so staff might not know how to support each person in the right way.
“All sections of the care plans were the same except for the detail on who the person can go to for help.” from the report
Activities and visits
needs fixingPeople and relatives said they would benefit from more activities. Inspectors saw no regular person-centred activities during the inspection, and relatives had previously been unable to visit inside.
“During our inspection we saw no evidence of any regular person-centred activity taking place.” from the report
- 01What evidence can you show that medicines are now stored at the correct temperature, recorded correctly and disposed of safely?
- 02How are individual risks, including self-harm, windows and emergency evacuation, now assessed and reviewed with each person?
- 03How have you made care plans more personal, and how are people and their relatives involved in writing and reviewing them?
- 04What training and medicine competency checks have all staff now completed?
- 05What regular activities are available, and what is the current policy for relatives visiting inside the home?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control, care, premises, records, staffing and management systems. This explanation was written from the published report of 12 November 2021 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 Fullwood House
4 rated inspections over 6 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- November 2021Requires improvementdown from GoodSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Registered with the Care Quality Commission on 2 October 2014.
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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