The latest Care Quality Commission report on Fleetwood Hall Nursing Home is now available.



This unannounced inspection of Fleetwood Hall took place on 22 June 2016.
Fleetwood Hall is a large care home set in its own grounds on the outskirts of Southport. The home is registered to provide accommodation for up to 53 people across three units. The units include:

a mental health unit that can accommodate men and women (separately) with enduring mental health needs, a dementia care unit that can accommodate six men and women and a general nursing unit for up to 14 people, both men and women.

The service was last inspected in November 2016, and at that time was found to be in breach of regulations 12 and 11 relating to safe care and treatment and consent. We had also made a recommendation under the ‘well-led’ domain with regards to the effectiveness of quality assurance systems. Following the inspection the provider sent us an action plan detailing what action they were going to take to address the concerns we found. We checked this as part of this inspection.

This inspection was ‘focussed’ in that we only looked at the two breaches of regulations to see if the home had improved and the breaches were now met. We also checked if quality assurance procedures had improved. This report only covers our findings in relation to these specific areas / breaches of regulations. They cover only three of the domains we normally inspect whether the service is 'Safe' ‘Effective’ and ' Well led'. The domains ‘Caring’ and ‘Responsive’ were not assessed at this inspection.

During this inspection we found that improvements had been made and the provider had taken action to address the concerns raised at the last inspection. Care plans were easy to read and follow, and information was accurate, complete and up to date. Additionally, documentation around people’s capacity was updated and recorded. The registered manager had also attended an advanced course in the principles of the MCA (Mental Capacity Act). The provider was no longer in breach of these regulations. We checked the quality assurance procedure during this inspection to ensure its effectiveness had improved since our last inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in November 2016, the service was in breach of regulations in relation to safe care and treatment. This was because some records relating to people’s care and treatment were disorganised, missing, or lacked a sufficient amount of clinical detail about that person. After the inspection the provider sent us an action plan detailing what action they were going to take and we checked this as part of this inspection.

The records we saw during this inspection had been re-organised into coloured coded sections. This made it easier to find information. Care plans and risk assessments had also been recently reviewed. The provider was no longer in breach of this regulation.

At our last inspection in November 2016, the service was in breach of regulations relating to consent. This was because the registered manager did not have a full awareness of DoLs and any conditions on people’s DoLs were not being appropriately managed. Best interest processes were not being considered for some people who did not have capacity to make decisions around their care. Following our inspection the provider sent us a list of actions detailing what steps they were going to take to address this, and we checked this during our inspection. We found that sufficient improvements had been made, and the provider was no longer in breach of this regulation.

During our last inspection, we found that procedures relating to the governance of the service had improved enough for the provider not to be in breach of regulation; however we did make a recommendation regarding this due to the inconsistencies we found with risk assessments and the MCA. We checked the providers approach to quality assurance at this inspection to see if any improvements had been made. We saw that the registered manager had adapted their quality assurance process to ensure that clinical information was checked and updated, also the nurse in charge was issued actions if there was anything which required following up. There was a new file in place which contained all the people who were subject to DoLS at the home, the application stage, and any conditions. This file was audited as part of the quality assurance process.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Fleetwood Hall' on our website at www.cqc.org.uk

http://www.cqc.org.uk/sites/default/...3264317562.pdf