Fremantle Court

Updated 26 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

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

Two inspectors visited the service on the first day of the inspection, 1 was a medicines inspector. They were accompanied by an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. One inspector visited the home for the second day of the inspection. A third inspector contacted staff by telephone after the site visits.

Service and service type

Fremantle Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Fremantle Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A manager had recently been appointed and started at the home a few weeks prior to the inspection. They intended to apply to become registered.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 1 August 2023 and ended on 18 August 2023. We visited the location’s service on 1 August 2023 and 4 August 2023.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We reviewed information we had received about the service and sought feedback from the local authority.

We used this information to plan our inspection.

During the inspection

We met and had discussions with staff including a quality manager, the manager, deputy manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with members of care, nursing and housekeeping staff.

We observed mealtimes and joined a daily heads of department meeting. We spoke with 10 people who used the service and 5 visitors.

We looked at all or part of 6 care plans, risk assessments and associated care and nursing records. We checked medicines practice and observed medicines administration. We checked records of audits and monitoring carried out by the provider. Other records we read included accident and incident logs, staff training records, recruitment files, staff rotas and records relating to safety and upkeep of the premises.

We contacted relatives by email to invite them to provide feedback about the service. We also contacted health and social care professionals. An inspector spoke with 26 staff on the telephone.

After the inspection

We requested and received additional records and evidence after the site visits and continued to review these until 18 August 2023.

Updated 26 August 2023

About the service

Fremantle Court is a care home providing personal and nursing care to up to 90 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 83 people using the service.

The home accommodates people in a purpose-built property with 6 wings. Each wing has single, en-suite bedrooms, with adapted bathrooms and lounge/dining areas close by. There are several quiet areas around the building as well as shared facilities, including a hairdressing salon and cinema room.

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

People told us they felt safe at the service. There were systems to protect people from abuse and staff told us they felt confident in speaking with senior staff and managers if they had any concerns. Risks to people’s health and safety were effectively managed and action was taken to minimise the likelihood of injury or harm. The premises were well-maintained, clean and regular checks were carried out to ensure it was safe.

There were enough staff to meet people’s needs. Staff had been recruited using robust procedures. People provided positive feedback about staff, although a couple of people felt there were some barriers to how their care was delivered where English was a second language for staff. For example, in how they were spoken with.

People received their medicines safely. Records were well-maintained and staff were regularly assessed to ensure they followed safe medicines procedures. We have made a recommendation regarding improving protocols for medicines prescribed for occasional use, in order that these are centred on the needs of each person.

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.

The service had experienced changes of managers over recent years. This was something staff, relatives, people who used the service and external agencies commented on. They were keen for the new manager to stay and told us about the improvements they had made in the short time they had been at the service.

Improvements had been made to records management and governance systems. There were systems to engage with people and seek their feedback. Staff were kept up to date with people’s health and well-being through handovers and daily morning meetings.

Community professionals spoke positively about how staff and managers engaged with them and listened to their advice, to improve people’s care. Relatives also told us how their family members’ health and well-being had improved since living at the service.

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 (report published 8 February 2023).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about medicines and staffing. A decision was made for us to inspect and examine those risks. We did not find evidence people were at risk of harm from these concerns.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.