Fairland House

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We were not assured that there were enough staff to meet people’s needs holistically and safely particularly at night when there was reduced staffing. The dependency tool did not accurately identify peoples needs to ensure staffing levels were appropriate. Some people had complex needs and cognitive needs and staff were not sufficiently trained or have access to professional guidance, support, and clear accurate records to follow. This a breach of regulation 18: Staffing of The Health and Social Care Act 2014. Risks associated with infection control and the environment had not been clearly identified and broken equipment, poor lighting and frayed carpets increased the risk of injury to people using the service. This a breach of regulation 12: Safe care and treatment of The Health and Social Care Act 2014. Governance and oversight was poor which meant audits did not always identify shortfalls so lessons could be learnt and improvements made in a timely way. People were safeguarded because staff understood how to raise concerns, but we were less assured that actions to mitigate risks were firmly established and embedded in practice. Medicines were given safely, and auditing processes had improved to ensure people received their medicines as intended. We were not assured however that there were enough staff at all times to give medicines as required or that the medicine competency assessments were sufficiently robust. Risk assessments for anti-inflammatory creams were not in place but were implemented immediately.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Processes were in place to protect people from avoidable harm, unfair treatment, or abuse. Staff received training in safeguarding and all other relevant training in line with the needs of people using the service and accessing adult social care. Policies were accessible and there was information available to staff and visitors about how to raise concerns. Provider oversight of incidents etc had only recently improved with the replacement of the management team and regular catch ups with the area manager to identify improvements and review action plans. Safe staff recruitment helped ensure people were protected from staff unsuitable to work in the industry, but we found gaps and a lack of auditing of staff records.

The provider did not have a good oversight of his service or what was important to people. They had failed to maintain high standards in relation to the environment, cleanliness and all aspects of peoples care to ensure they were safe. Risks to some extent were mitigated because people had equipment they needed and were checked regularly for their safety but there was poor analysis of risk. Weekly multi-disciplinary meetings were taking place which meant there was collaborative working to try and ensure people received joint up care and any changes identified were addressed. The deputy manager who had come into post 7 weeks earlier had a good oversight of peoples needs and records had been digitalised by the area manager also new to post. Handover procedures had improved, and concerns were being reported to the local authority and CQC as appropriate.

During our site visit we spoke to and observed peoples care, we also spoke to relatives off site. We were not assured that risks were managed holistically or in line with people’s needs. We were told by the area manager that no one was able to use the stairs safely and had to wait for staff to assist. This impeded people’s independence. Relatives told us that they did not think their family members were always safe. Their concerns included : Continence management with people being left wet for longer than the family member would have liked. Relatives attributed this to staffing and one complained about his family member not being supported out of bed until almost lunch time and said it took several complaints before this issue was addressed. Concerns about falls were raised and some of these were linked to supervision of people. One relative said staff tend to congregate in the same area and have chats amongst themselves rather than supporting people. Communication and English as a second language was a concern relatives raised and said their family members could not always understand what was being said and staff could not always understand what they were being asked to do. This could increase the risk of unsafe care being provided. One person told us that staff from oversees were extremely pleasant and they had a laugh whilst trying to work out how to put on their support stockings. They did feel more basic training needed to be offered. None of the relatives and indeed the person able to comment on their care were aware of the digital care plans or how they could contribute or access these and we found the care plans were inaccurate and not reviewed as required.

Observation were favourable this was a nice home with lots of communal and private space, nice bedrooms and shared facilities. However, the dining room was not big enough should everyone want to use it and the kitchen was not particularly accessible to people using the service. Equipment was broken including radiators coming off the wall which could increase the risk of scalding. Maintenance checks were regular but often only included a sample ie 4 call bells rather than looking at everything which was not particularly robust. We found the home clean but there were areas which were not and these had not been identified by the provider. The gardens were particularly spacious.

People lived in a warm comfortable environment. However, it was not easy for them to navigate and there was a lack of signage. The house was homely but there was poor flooring and poor carpeting. We did not observe many people using the facilities the home had to offer but spending time in their rooms which were comfortably furnished and clean except one room where the risks of poor infection control had not been well established. Refurbishment was underway and there was a beautiful garden which people said they enjoyed, although one person said she no longer accessed the garden through fear of setting off the alarm, relatives told us it was difficult to get in or out of the home. Audits were carried out and people did not have concerns about cleanliness or maintenance.

The action plan had been developed and reviewed following concerns from the local authority. Work had already commenced and a deep clean had taken place. However current audits did not demonstrate domestic staff were adequately supported or that regular cleaning of all areas were taking place. We were not satisfied with areas of cleanliness including poor standards in the kitchen, a dirty toilet, and dirty cups. One room was not clean and the risks of this had not been mitigated. The manager said they had the support of the provider to make all the necessary improvements to the home and had already started to decorate and create nice spaces for people including a reminiscence area. Chairs were in good condition and a mattress in the hall was moved immediately. The manager agreed lighting was inadequate and the hallway was dark. They were looking to address this and to review the flooring and stair gate which meant parts of the home were inaccessible to people and had not clearly been risk assessed. There was a clear commitment to improve the quality and condition of the service. Maintenance schedules were in place, but the manager was reminded that any actions should be included on the action plan to show if and when they should be addressed.

The manager had been in post for five days and the deputy manager about seven weeks at the time of our site visit. Both appeared very knowledgeable and had a clear vision for the home. They had already started to review staffing and develop a new dependency tool which more accurately reflected the needs of people using the service. On our initial feedback they increased night staff to a minimum of three as we expressed concerns about fire safety and potential risks with such low staffing numbers. Recruitment was being addressed and the manager had recognised that they needed to consider recruiting from the local community and during out assessment process had already been able to fulfil some of their vacancies.

We reviewed rotas and found these contained gaps and did not always accurately tell us if shifts were covered by agency or overtime. Frequent gaps on the staffing rotas indicated shifts fell below the number of staff required. This would have an impact on the quality and safety of care. Staff vacancies and the recruitment of staff from oversees had resulted in inconsistencies in care. Staff had received basic training but there was a lack of observation and supervision for staff to ensure they had understood and were able to embed their training. The dependency tool used by the provider was not sufficiently detailed to accurately calculate how many staff were necessary to keep people safe. It did not consider the lay out of the building, the levels of supervision people might need and the complexities of people living with sensory needs, mental health needs and histories of self-neglect. Neither did it consider additional resources necessary for people who were requiring palliative care. New admissions to the service were happening despite widespread concerns about the standards of care and the local authority taking actions to restrict admissions. The recent admissions had been private and therefore no restrictions were in place for these. However, until there was a full compliment of staff who could demonstrate they could work effectively we had concerns about people’s safety.

During our site visit the provider had the number of staff they said they needed, and we were advised of a recent admission to the service and another one pending. In addition to senior staff and care staff there were management on site and ancillary and activity staff. Throughout our observations we found staff were working hard all morning trying to assist people with their personal care and breakfast which was provided in line with peoples needs. Lunch was well executed with people receiving the support they needed. The atmosphere was calm. Most people were in their rooms all morning and were not engaged in ‘house activities’ and for people on the first floor they would need support from staff to attend activities and access the ground floor. We were concerned about any drop in staffing numbers which was the case in the evening, weekend and overnight. Two-night staff were on duty at any one time, and this was woefully inadequate given the number of people who required two staff to assist them with their mobility needs. There was only one activity member of staff, and they were not employed seven days a week and struggled to get round to everyone to support them. There was only one domestic on duty, and this was a large home. We were told night staff helped with cleaning, but we challenged this notion as night staff already had so much to do including hourly checks over two floors.

During our site visit we found individual rooms and communal areas clean with no unpleasant odours. However, on deeper inspection we found areas of concern including the kitchen, which was not particularly clean, and the floor was being replaced. We found a toilet that was out of action on the first floor and a toilet downstairs where faeces were smeared on the wall. There were no records to show frequently used areas liked shared toilets were subject to additional checks. We were unable to speak with domestic staff as they were working flat out and doing an exceptional job given the size and age of the home. We observed staff following good hygiene steps and encouraging people to wash their hands before meals.

Cleaning schedules were in place but were not completed regularly and we had concerns about staffing levels and how realistically they could complete both scheduled cleaning and deep cleaning of the home. It was the local authority and not the provider who highlighted in their visit in December that the home was failing to maintain high standard of cleanliness and as an action had asked the provider to get the home deep cleaned. This had been completed to good effect, but we were concerned the home did not have enough resources to continue to maintain the cleanliness of the home and reduce the risk of cross infection.

The manager was aware of gaps in staffing and had set about to recruit a housekeeper and additional staff. Gaps in cleaning records were brought to their attention and they agreed to review it. Audits were taking place which included the cleanliness of the service and staff received training in infection control.

Medicine administration had improved but we still had concerns that not enough staff were trained, and the management team could not demonstrate that there was a competent person on duty 24 hours a day should someone require medicines in the evening. The manager said there was an effective on call system and they could respond to peoples needs as required. We however said there needed to be someone trained to give medicines at all times. We also questioned the competency assessments completed for staff who could give medicines, these were not very detailed and did not satisfy us staff were competent. Regular auditing and communication with health care professionals was improving safety around medicines and we observed staff giving medicines and this was completed in a timely, sensitive way.

The deputy manager had worked hard to review medicines and medicine practices to ensure people had the medicines they needed, and these were given in line with the prescriber’s instructions. Clearer audits had resulted in fewer errors being recorded as identified by the local authority visit in December 2023. There was better communication with the GP practice and pharmacy to help ensure prescriptions and changes to medicines were properly authorised and people’s medicines were reviewed. A number of anomalies were identified by our medicine’s inspector, but these were rectified on the day. We raised the issue of person-centred practices around the administration of medicines. People’s creams were stored in a locked room downstairs. The manager said this was because it got too hot upstairs so couldn’t be stored in people’s rooms although they had locked cupboards. We felt that some people could be supported and assessed to manage part of their own medicine administration such as creams. The current system was very time consuming for staff. We also noted the people with emollient creams did not have a fire risk assessment in place and this was a known risk if creams came into contact with fire. There was also contradictory information about whether anyone smoked at the service which would increase the risk. We identified that staff and at least one person smoked which placed people at increased risk which had not been identified by the provider. The manager put risk assessments in to place immediately upon feedback.