Archived: Fitzroy Lodge

Updated 8 February 2023

The inspection

This was a targeted inspection to check on concerns we had about the suitability of the premises to safely accommodate people and whether the provider was fit to operate.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by two inspectors.

Service and service type

Fitzroy Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a manager registered with the CQC although they were no longer employed in their post. The provider had employed another manager who, at the time of the inspection, was applying to be registered with CQC.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. Prior to the inspection we were unsure whether anybody was being supported at the home and we wanted to be sure there would be staff at home to speak with us.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

At the time of the inspection, there were no people living at the home. We spoke to three members of staff, the provider, the manager and the environmental compliance manager. We made extensive observations of the environment of the home and the redevelopment work being completed. We looked at the care plans and risk assessments of the person who had previously been admitted for respite care. We looked at the recruitment files of three members of staff, including the manager. We reviewed the providers action plan for the home.

Updated 8 February 2023

About the service

Fitzroy Lodge is a residential care home providing accommodation and personal care for up to 24 people in one adapted building. The service provides support for people living with a range of health care needs, including people living with dementia. There were 15 people living at the home on the first day of our inspection, this had reduced to 11 people on the third day of our inspection because some people had moved to other services.

People’s experience of using this service and what we found

There were wide spread concerns about the quality and safety of the service. People were at risk of abuse and neglect. Staff did not recognise or respond appropriately to signs of potential abuse. We raised safeguarding alerts for people with the local authority who took immediate action to make people safe and a police investigation began.

There were widespread failings in the management of the service. The provider did not have effective systems in place to ensure they retained oversight of the service and this had allowed a closed culture to develop. We took urgent action to impose conditions on the provider’s registration to address management issues.

Risks to people were not always assessed and monitored effectively and people were at risk of harm. Some people were at risk of choking but were not receiving the support they needed. Risk assessments and care plans were not comprehensive. Some people had health conditions and the impact and associated risks had not been considered. This meant that staff did not have all the information they needed to provide safe, effective care in a personalised way. The provider was relying on the use of agency staff who did not know people well, this increased the risks to people. There were not always enough suitable staff deployed to support people’s needs.

Systems for managing medicines were not effective. There were not always staff on duty who were trained and competent to administer medicines. Records relating to medicine administration and disposal of medicines were not accurate. This meant the provider was not able to account for some medicines. People were prescribed creams for skin conditions, but these were not being consistently applied and some people had developed sore and itchy skin as a result.

Infection prevention and control measures were not effectively managed. Staff were not clear about testing arrangements for COVID 19 and the lack of records meant that the provider could not be assured that tests had been completed consistently. There was no system in place to check the COVID status of staff before they came into contact with people and other staff in the building. The poor condition of the environment throughout the property meant that it was difficult to ensure cleanliness was maintained.

People were not always receiving the support they needed with food and drinks. Several people had unplanned weight loss but there was no record of actions taken to address these concerns. Record keeping was inconsistent, and this meant the provider could not be assured that people were receiving the food and fluids they needed. The quality of food was poor with mainly frozen food and a lack of fresh fruit and vegetables.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support good practice. Some people had conditions placed on their authorisation to deprive them of their liberty. There was no system in place to ensure these conditions were met and staff did not know or understand their responsibilities to comply with these conditions. Records did not identify that people had consented to restrictions or how decisions were made in people’s best interest if they lacked capacity.

Most people and relatives said staff were caring and they liked them. However, some people told us staff were not always kind to them. A person told us how a staff member, “Told them off,” and described them as being unpredictable saying, “They are alright sometimes, if they are in a good mood.” A relative raised concerns about how staff spoke to people and to them. Not all staff knew people well and some staff did not support people’s dignity. The language used in daily records suggested a culture where people were not always respected, and their needs were not well understood.

People were not receiving care and support in a personalised way. Staff did not know people well and care plans did not provide enough detail to enable staff to care for people in a personalised way. Staff were not always responsive to changes in people’s needs. There were few opportunities for social stimulation. One person told us they spent their time waiting for their family to visit. Complaints from people or their relatives were not always recorded and addressed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update): The last rating for this service was requires improvement (published 1 October 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The rating for the service has deteriorated to inadequate.

Why we inspected

The inspection was prompted due to concerns received in relation to safeguarding people, and the management of the home. A decision was made for us to inspect and examine those risks. 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.

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 have identified multiple breaches at this inspection in relation to people’s safety and well-being, management of risks, food and drink, seeking consent, staffing, treating people with dignity and respect and the management and oversight of the service. We took urgent action to ensure people’s safety.

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

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.