CQC report explained · a residential care home
What the CQC found at The Firefly Club Care Home
Not yet rated: the CQC has not published a rated inspection for this home, which is usual for a new registration.
What inspectors found, September 2023
The Firefly Club Care Home is rated Requires Improvement overall; care was kind and personalised, but safety records and management checks were not consistently reliable.
This was an unannounced follow-up inspection after the service was previously rated Inadequate and placed in Special Measures. One inspector visited on four dates and spoke with people, relatives, staff and a health and care professional. They also observed care and checked care, medicines, staff and management records.
The inspectors found clear improvements. Care plans were more personalised, staff understood people's needs, and people were treated with kindness and respect. People were supported to make choices, stay independent, use local services and keep in touch with family and friends. The Effective, Caring and Responsive ratings were Good.
Some important checks and records were still incomplete. Risk plans did not always give enough detail, some medicines records missed administration times, and financial records in the domiciliary service were not detailed enough. Cleaning, monitoring and temperature records were also incomplete. The provider remained in breach of Regulation 17 on good governance.
The overall rating improved from Inadequate to Requires Improvement. The service was no longer in Special Measures, but CQC asked for an action plan and said it would continue monitoring progress.
Personalised care
Care plans had been reviewed and made more individual. People and relatives were involved in developing them.
“Care planning documentation was now personalised, and people confirmed they were involved in developing their care plans.” from the report
Kind and respectful staff
Inspectors saw positive relationships and patient communication. People were given time to understand information and make choices.
“We observed positive interactions between people and staff. People were spoken to respectfully and patiently and offered regular opportunities to engage.” from the report
Support for independence
People were encouraged to take part in everyday tasks and were supported to use community facilities and public transport.
“People had been supported to access local amenities with friends and family and to make meaningful contacts within their communities.” from the report
Improved staffing and training
Staffing levels and training had improved since the previous inspection. The manager had systems to monitor training and used regular agency staff who knew people.
“People and staff told us there were enough staff. Our observations during the inspection confirmed this.” from the report
Progress since the last inspection
The service improved from Inadequate and left Special Measures after showing progress in six of the previous areas of breach.
“The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.” from the report
Governance breach
seriousManagement systems did not reliably identify risks or incomplete records. This included risk plans, cleaning records, monitoring forms, temperature records and exercise notes.
“The failure to operate effective systems to assess, monitor and improve the service, monitor and mitigate risks and maintain accurate and complete records was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Risk plans lacked detail
needs fixingSome plans did not fully explain the steps staff needed to take to manage risks. Inspectors gave pressure ulcer prevention as an example, although staff knowledge helped reduce the risks.
“Some risk management plans still required more detail to make them fully robust.” from the report
Financial records
needs fixingIn the domiciliary service, records of some financial transactions were not detailed enough. This could make it harder to spot discrepancies promptly.
“Some people were at increased risk of financial abuse in the domiciliary service as records of financial transactions were not completed in detail.” from the report
Incomplete medicines records
needs fixingThe administration time for some as-required medicines was not always recorded. The provider was developing stronger checks, but these were not yet established.
“The administration of PRN medicines had not always been effectively recorded on the medicine administration record.” from the report
Fire-drill records
needs fixingRecords did not show that all staff, including night staff, had taken part in fire drills. The manager planned to add drills for different times of day and night.
“The fire drill records did not demonstrate all staff, including night staff, had been included in fire drills.” from the report
- 01What actions and deadlines are in the current plan to address the Regulation 17 breach?
- 02How will you make sure every person's risk plan contains full guidance, including plans for pressure ulcer prevention and emergencies?
- 03How will you check that as-required medicines are recorded with the correct administration time?
- 04How are financial transactions in the domiciliary service now recorded and checked for possible discrepancies?
- 05When will all staff, including night staff, take part in fire drills, and how will this be recorded?
This was an unannounced follow-up inspection of the care home and domiciliary care service, covering all five key questions and infection prevention and control measures. This explanation was written from the published report of 7 September 2023 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, January 2023
The Firefly Club Care Home was rated Inadequate and placed in special measures because inspectors found serious safety, staffing and leadership failures.
Inspectors visited unannounced on 1, 2 and 5 December 2022. One inspector observed care, spoke with staff, relatives and a professional, and checked care plans, medicines, staff files, training records, risk assessments and management records.
The home was not safe or effective. Care plans and risk assessments were incomplete, out of date or contradictory. Medicines records had gaps, some equipment and fire safety checks were missing, recruitment checks were incomplete, and many staff did not have the training needed for people's needs.
Care was rated Requires Improvement because staff were often kind, but people did not always receive consistent, person-centred support or reliable communication. Leadership was rated Inadequate because there was no registered manager, oversight was weak, records were incomplete and staff morale was low. The overall rating fell from Good at the previous inspection in 2019.
Kind staff
Relatives generally spoke positively about staff's caring attitude. Inspectors also saw some warm and respectful interactions.
“Staff are kind and caring. Nothing but good things about staff.” from the report
Healthcare access
People had access to physical healthcare and relevant professionals, including the community learning disabilities team.
“People had good access to physical healthcare and were supported to live healthier lives.” from the report
Contact with relatives
Relatives could visit without restrictions, and people were supported to keep in touch by video call.
“The provider facilitated visits for people with their relatives and friends in accordance with government guidance.” from the report
Choice of spaces
The home had several shared and quiet spaces, giving people different places to spend time or have privacy.
“The service was spacious with large shared spaces.” from the report
Communication support
Some people were supported with communication aids, Makaton and social stories.
“We saw people being supported with their communication aids and some staff were observed supporting people with Makaton.” from the report
Unsafe care plans and risk records
seriousCare plans and risk assessments were incomplete, out of date or contradictory. This meant staff could follow inconsistent guidance and people were at increased risk of harm.
“This meant people were at an increased risk of harm by being supported by staff following inconsistent care planning documentation.” from the report
Medicines records
seriousThere were gaps in medicines administration records and some instructions for as-required medicines were not detailed enough. The home could not show that medicines were always managed safely.
“We found multiple gaps on medicine administration records (MARs) for 3 people.” from the report
Staff training and staffing oversight
seriousStaff did not always have current training for people's needs, including autism, learning disabilities and emergency medicines. The provider could not be sure that enough suitably trained staff were available.
“This meant people were at an increased risk of harm by being supported by staff who were not adequately trained.” from the report
Fire and equipment checks
seriousFire safety records, wheelchair checks and other equipment checks were missing or incomplete. Broken fire door stops and unresolved maintenance created additional safety risks.
“This meant the provider could not be assured the premises remained safe for people.” from the report
Limited person-centred support
seriousPeople were not always supported to make meaningful choices, build independence or take part in suitable activities. Staff sometimes used different approaches because care plans lacked clear guidance.
“People did not always receive care that was planned, personalised or responsive to their needs.” from the report
Weak leadership and staff confidence
seriousThere was no registered manager and quality systems did not identify serious problems. Some staff were afraid to raise concerns and morale was low.
“Staff did not feel confident in raising concerns with the provider.” from the report
- 01Which care plans and risk assessments have now been rewritten, and how do you check that staff follow the current versions?
- 02How do you check that every medicine is available, given correctly and recorded without gaps?
- 03Which staff are currently trained and assessed as competent to support people with autism, learning disabilities, NAPPI and emergency medicines?
- 04How are fire doors, wheelchairs and moving and handling equipment now checked and repaired?
- 05Who is currently managing the home, and how can families see evidence that the improvement plan is being completed?
This was an unannounced comprehensive inspection covering all five key questions, the premises, care and infection prevention measures; six people's records and five people's experiences were examined. This explanation was written from the published report of 31 January 2023 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of The Firefly Club Care Home
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2023Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2018
Registered with the Care Quality Commission on 23 November 2018.
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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