Fitzwarren House

We identified 2 breaches of the legal requirement in relation to safe care and treatment and governance. Risks were not always fully assessed or managed, including in relation to safeguarding, fire safety and medicines management. Some care records did not contain sufficient information to guide staff in managing health-related risks, and Mental Capacity Act requirements were not consistently applied. Staffing levels and staff training did not always meet people's needs. Some people reported delays in receiving support.

Infection prevention and control measures were not always effective for example, areas around the service were malodourous and visibly unclean. Whilst audits and quality assurance processes were in place, actions identified through these processes were not always completed, followed up or sustained. People’s information was not always stored securely; shortfalls were not always identified and records showed previous concerns had not always resulted in effective and lasting improvements.

We have asked the provider for an action plan in response to the concerns found at this assessment.

The provider effectively supported continuity of care, involving people in decisions about their care and treatment, and promoted choice and independence. Healthcare professionals spoke positively about the nursing team's knowledge and competence, and people told us they felt treated with dignity and respect. Staff were observed interacting with people in a warm, caring and person-centred way, and relatives described the service as friendly and supportive.

The provider had systems in place to share learning from incidents and worked collaboratively with external professionals. People were able to access healthcare services when required, and care records reflected efforts to understand people's preferences, life histories and what was important to them. The provider demonstrated positive partnership working with healthcare professionals, who described staff and managers as approachable and receptive to advice and support.