We carried out a review of the data available to us about Fradel Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Fradel Lodge, you can give feedback on this service.
Fradel Lodge is an extra care housing scheme. There were 16 people receiving a personal care service living in ordinary flats in one scheme. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.
People’s experience of using this service
People were protected from the risks of harm and abuse. Staff were knowledgeable about the actions to take if they suspected somebody was being harmed or abused. People had risk assessments to minimise the risks of harm or abuse they may face. Staff were recruited safely and there were sufficient staff on duty to meet people’s needs. People were protected from the risks associated with the spread of infection. Medicines were managed safely.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People’s care needs were assessed before they began to use the service. Staff were supported to carry out their role with training, supervision and appraisals. People were supported with their nutrition, hydration and health. Staff understood their responsibilities under the Mental Capacity Act (2005).
People thought staff and the management were caring. Staff knew people well and understood how to deliver a fair and equal service. People and relatives were included in the decision making around the care provided to them. People confirmed staff understood how to promote their privacy, dignity and independence.
Staff knew how to provide a personalised care service and were knowledgeable about people’s individual care needs. People’s communication needs were met. People were encouraged to participate in activities including their religion and maintaining family contact. Complaints were dealt with appropriately. People who were at the end of their life had their last wishes documented.
People and staff spoke positively about the leadership in the service. The provider held regular meetings for people using the service and staff. The provider had a system of checking the quality of the service provided to identify areas for improvement. The provider worked in partnership with other agencies to improve outcomes for people.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 13 September 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
There was a registered manager at the service. 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.
The provider was meeting the requirements of the Mental Capacity Act 2005. Mental capacity assessments were in place to demonstrate that where people could not consent to their care, decisions were made appropriately in their best interests. Care staff demonstrated knowledge of their responsibilities under the Mental Capacity Act 2005.
Quality assurance systems were thorough. The manager completed various audits and took action to implement required changes as a result of the last Care Quality Commission inspection. We saw evidence that feedback was obtained from people using the service and the results of this was positive. Notifications were submitted to CQC as required.
Procedures were in place to protect people from abuse. Staff knew how to identify abuse and knew the correct procedures to follow if they suspected abuse had occurred. Safeguarding matters were reported to the CQC as required.
We saw evidence of logging of accidents and incidents and evidence of investigations and further analysis into the causes of accidents and incidents. We saw consequent further action was taken as a result to mitigate risk.
Staff had completed medicines administration training within the last year and were clear about their responsibilities.
Risk assessments and support plans contained clear information for staff. All records were reviewed every month or where the person’s care needs had changed.
Staff demonstrated an understanding of people’s life histories and current circumstances and supported people to meet their individual needs in a caring way.
People using the service and their relatives were involved in decisions about their care and how their needs were met. People had care plans in place that reflected their assessed needs.
Recruitment procedures ensured that only staff who were suitable, worked within the service. There was an induction programme for new staff, which prepared them for their role. Staff were provided with appropriate training to help them carry out their duties. Staff received regular supervision. There were enough staff employed to meet people’s needs.
People were supported to maintain a balanced, nutritious diet. People were supported effectively with their health needs and to access a range of healthcare professionals.
People using the service and staff felt able to speak with the manager and provided feedback on the service. They knew how to make complaints and there was a complaints policy and procedure in place.
There was a registered manager at the service. 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.
Procedures were in place to protect people from abuse. Staff knew how to identify abuse and knew the correct procedures to follow if they suspected abuse had occurred. However, safeguarding matters were not reported to the CQC as required.
We saw evidence of logging of accidents and incidents, however, we did not see consistent evidence to demonstrate investigations were always conducted into accidents and incidents.
Staff had completed medicines administration training within the last year and were clear about their responsibilities.
Risk assessments and support plans contained clear information for staff. All records were reviewed every month or where the person’s care needs had changed.
The provider was not meeting the requirements of the Mental Capacity Act 2005. We saw examples of documentation being signed by next of kin without them having the legal authority to do so and one person’s liberty was being unlawfully deprived. However, care staff demonstrated knowledge of their responsibilities under the Mental Capacity Act 2005.
Staff demonstrated an understanding of people’s life histories and current circumstances and supported people to meet their individual needs in a caring way.
People using the service and their relatives were involved in decisions about their care and how their needs were met. People had care plans in place that reflected their assessed needs.
Recruitment procedures ensured that only staff who were suitable, worked within the service. There was an induction programme for new staff, which prepared them for their role. Staff were provided with appropriate training to help them carry out their duties. Staff received regular supervision. There were enough staff employed to meet people’s needs.
People were supported to maintain a balanced, nutritious diet. People were supported effectively with their health needs and were supported to access a range of healthcare professionals.
People using the service and staff felt able to speak with the registered manager and provided feedback on the service. They knew how to make complaints and there was a complaints policy and procedure in place.
Quality assurance systems were not consistently thorough. The registered manager completed various audits, but these did not identify the issues we found in relation to consent. We saw evidence that feedback was obtained by people using the service and the results of this was positive.
We found two breaches of regulations in relation to consent and notifications. You can see what action we told the provider to take at the back of the full version of this report.
People using the service told us they were always asked for their consent before staff provided personal care and their views were listened to.
People's personal care was planned, delivered and monitored in a way that was intended to ensure their welfare and safety.
There were systems in place to ensure that people received safe and appropriate support with their medicines, in accordance to their assessed needs.
People told us there were sufficient staff available to provide their personal care in a manner that felt thorough and not rushed.
The provider regularly checked upon the quality of the service and acted upon people's views in order to make improvements.
People told us they were well cared for and provided with an individualised service. One visitor told us they called in every day at different times and felt reassured their relative was happy and comfortable. They told us the standard of care was high and the staff were kind and helpful.
The care needs of people using the service were assessed and recorded in their care plans. Risk assessments had been carried out in order to ensure people's safety.
We found that staff were provided with training and support. Staff told us they enjoyed the training programme and were offered opportunities for professional development.
People using the service and their representatives were asked for their views about their care and they were acted on.
There were suitable arrangements to involve people in decisions about their care and support, and their needs were regularly reviewed.
There were sufficient care workers on duty at the time of our inspection, and the staff members we spoke to told us they felt supported in the service.