Fallowfield

Updated 31 December 2022

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

This inspection was undertaken by one inspector, a specialist advisor nurse, a member of the CQC medicines team and 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.

Service and service type

Fallowfield 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. Fallowfield 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 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 registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had about the service since they registered. We sought feedback from the local authority and professionals who work with the service. 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. We used all this information to plan our inspection.

During the inspection

We spoke with 10 people living at the service and 2 relatives to seek their views about the quality and safety of the care and support provided. We observed interactions between people and staff to understand people's experiences and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with 10 staff including the registered manager, nursing staff, care staff, activities coordinator, kitchen and housekeeping staff. We reviewed a range of records including 10 people’s care records and medication records, 4 staff files in relation to recruitment and staff training and a variety of records relating to the management of the service including quality monitoring checks and audits and policies and procedures.

Updated 31 December 2022

About the service

Fallowfield is a care home providing personal and nursing care for up to 25 people. At the time of our inspection there were 23 people living at the service. Fallowfield is a nursing home set in a Victorian mansion within large landscaped gardens. They provide nursing care and support to people with nursing needs.

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

People’s medicines were not always safely managed. Risks to people were assessed and documented, however, risk assessments and care plans were not always updated to reflect changes in people’s needs and some lacked detailed guidance for staff on how best to manage people’s needs and risks. Management staff completed regular audits of the service and had identified the issues we found in this report; however, we were not assured that appropriate actions were taken in a timely manner to address these issues and this required further improvement. Staff knew how to support people to keep them safe. Appropriate recruitment checks took place before staff started work and staff were deployed effectively throughout the home. There were systems in place to monitor, investigate and learn from incidents and accidents. There were procedures in place to reduce the risk of infections and staff followed good standards of infection control and hygiene practices.

People’s needs were assessed when they moved into the home to ensure they were safely met. Staff had the skills, knowledge and experience to support people appropriately. Staff were supported through induction, training and supervision. People were supported to maintain a healthy balanced diet and had access to health and social care professionals when they needed them. Health and safety checks were carried out of the premises and equipment to ensure they were safe. The home environment was clean and tidy, and the design of the premises met people's needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People and their relatives were consulted about their care and support needs. People were supported to participate in a range of activities and events within the home. Relatives were free to visit people if they wished without any unnecessary restrictions. Staff understood the importance of working within the principles of the Equality Act and supported people in meeting their needs. There was a complaints procedure in place and people were confident their complaints would be listened to and acted on. The registered manager and staff worked in partnership with health and social care professionals to plan and deliver an effective service to people. People’s views were taken into account to help drive service improvements.

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 28 January 2021).

Why we inspected.

This inspection was prompted by a review of the information we held about this service.

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 and recommendations

We have identified two breaches of regulation in relation to safe care and treatment and the safe management of medicines. We have made a recommendation in relation to the providers quality audits and checks ensuring action plans are implemented to monitor actions taken to address issues identified.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will continue to monitor information we receive about the service, which will help inform when we next inspect.