We carried out a review of the data available to us about Fairburn Vale 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 Fairburn Vale, you can give feedback on this service.
We found the following examples of good practice.
We observed systems and processes in place, in line with guidance, to ensure visitors to the home did not introduce and spread Covid-19. All visitors, including professionals, were subject to a range of screening procedures, including showing evidence of Covid-19 vaccination and a negative lateral flow test before entry into the home was allowed.
Staff followed government guidance in relation to personal protective equipment (PPE). We saw all staff were wearing face masks. Hand sanitiser and PPE was readily available throughout the service. The home had sufficient supplies of PPE.
All staff and people living at the home were being Covid-19 tested in line with current guidance. Appropriate processes were in place should anyone display any symptoms of Covid-19.
The care home was clean, well maintained and odour-free. Daily cleaning schedules were in place.
Staff supported people’s social and emotional wellbeing. Alternative forms of maintaining social contact were in place including video calls.
All staff had undertaken training in infection prevention and control (IPC) and PPE.
Policies and audits relating to infection prevention control, including coronavirus were up-to-date. We saw that regular IPC audits had been undertaken and the home had actioned the findings of the audits.
Fairburn Vale is a purpose-built facility offering specialist nursing care for 20 adults with acquired brain injuries, and accommodation for people with complex physical and mental health or behavioural needs. Accommodation is provided over two floors accessible by a lift and there is a communal garden area. There
were 20 people living in Fairburn Vale on the day we inspected.
People’s experience of using this service and what we found
People felt safely supported and there were secure relationships with staff, who knew people very well. Individual risk assessments were documented well in care plans and guidance for staff was very clear so they could support people safely. For example, positioning regimes, triggers for seizures and information about non-verbal communication cues.
Staffing levels on the day of the visit were below the provider’s expectations, although they tried to minimise the impact on care delivery by utilising the support of the wider staff team. Feedback we received about staffing levels was mixed. Some people and staff said there weren’t enough staff to support the service properly, whilst others said staffing levels were good.
Infection prevention and control measures were securely in place and known by staff, people who used the service and relatives. Clear information for staff about COVID-19 has been continuously delivered, from both a practical and supportive perspective. PPE was worn appropriately, although there was the occasional touching of masks, which the management team agreed to address immediately. Feedback from relatives about COVID-19 safety was the service ‘went above and beyond’ to ensure people’s safety.
Safety related training was completed and the staff training champion ensured compliance. Some practical training, which had been difficult to source during the pandemic, was being arranged. Staff felt supervision and training was relevant to the individual needs of people being supported. Staff were confident in their roles and to approach the management team with any development or further training needs. Staff felt confident to identify safeguarding signs of concern and to speak up if they had any. Medicines were managed safely overall, with clear recording. Staff competence was checked to ensure safe practice with administering medicines.
People were supported with healthy lifestyles and encouraged to make their own choices and decisions. Information about people’s mental capacity was clearly recorded. Mealtime support was in place, with lovely interaction between people and the staff. Staff knew people’s dietary needs well, although there was no information readily available, such as in the kitchen, to show people’s dietary needs for staff less familiar, such as agency staff. We made a recommendation for the provider to improve the quality of information available.
The key values and vision of the service were known by staff and on display in the home. Positive feedback was received about the management team and their supportive approach. Relatives felt very well informed and described the service as being ‘like family’. The provider ensured continuous health and safety monitoring was in place, as well as thorough responses to concerns raised internally and externally.
There was a clearly set out governance model; quality checks were robustly carried out, with close management oversight of the service. Clinical governance meetings and staff meetings were used for information sharing and driving improvements. Audits were detailed and identified areas to improve, actions taken to address matters raised and continuous monitoring of actions taken. Adverse events, such as poor moving and handling, choking incidents and medication errors, were thoroughly investigated and reviewed, with root cause analysis and clear actions taken to prevent occurrence. Opportunities for lessons learned were maximised with all staff through reflections, memos and further training where needed. Complaints and compliments were recorded well and responses made. Relatives had confidence in the complaints process. One particular compliment made was ‘Fairburn stands out as a light in a very dark year’ and highlighted the support for people and relatives throughout the challenges of the COVID-19 pandemic.
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 Good (report published 10 October 2017). The rating for this inspection remains Good.
Why we inspected
This was a planned inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link Fairburn Vale on our website at www.cqc.org.uk.
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.
At the last inspection in March 2015, the service was rated Good. At this inspection we found the service remained Good.
People were safe as staffing levels were appropriate to meet people’s needs in a prompt and organised manner. Staff knew how to report any concerns and how to recognise signs of abuse. Medication was stored, administered and recorded correctly and risks were managed to minimise the likelihood of harm.
Staff had received regular supervision and training to ensure they were fully equipped to perform their roles competently. They supported people in line with their support needs in regards to nutrition and hydration, and also in accessing external health and social care support where required.
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.
Staff displayed kindness, sensitivity and empathy in their interactions with people ensuring all their needs were met, both physical and emotional. People were involved as much as they were able in all decisions regarding their support needs and encouraged to participate in the life of the home.
Activities focused on individual needs and there was a programme to implement a wider range of pastimes and events. Complaints were handled with sensitivity and understanding, and all concerns addressed in depth.
The home was well managed with clear leadership and an organised staff team whose focus was ensuring all people living at Fairburn Vale had the best quality of life possible.
Further information is in the detailed findings below.
This was an unannounced inspection which took place on 17 March 2015.
Fairburn Vale provides nursing and social care to 20 people with an acquired brain injury, some people are supported to regain their independence and to move on from the service, and other people need longer term care. On the day of our inspection there were 20 people living at the home. The home is purpose built and all rooms have access to en suite facilities. There is level access to a secure garden and communal areas within the home.
There was a registered manager in post. 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.
Staff were aware of how to safeguard people who used the service. People’s needs were assessed and risks were identified and managed, we saw detailed risk assessments were in place. The service had systems and processes in place to protect people from harm and to ensure care was delivered safely.
We found people were cared for by sufficient numbers of suitably qualified and experienced staff. Robust recruitment and selection procedures were in place. Staff received the training and support required to meet people’s needs. Staff spoke positively about the amount and variety of training available to them.
Staff told us they were well supported, the service offered robust off site induction training. staff had access to regular supervision and everyone had received an annual appraisal. Staff told us the leadership team were supportive and they were confident any concerns raised would be investigated thoroughly.
We looked at the administration of medication and found people were being given their medication as prescribed. We found the recording of the medication administered was good. Staff told us they had received the training required to administer medication safely.We saw people had access to one to one activity, which was person centred. People were supported to maintain strong contact with their families and to develop links with the community.
Staff were trained in the principles of the Mental Capacity Act 2005. Deprivation of Liberty Safeguards (DoLS) were in place to protect the rights of people’s whose freedom was restricted. People were referred to advocacy services where appropriate.
Suitable arrangements were in place and people were supported and provided with a choice of suitable healthy food and drink ensuring their nutritional needs were met.
Health, care and support needs were monitored, assessed and met by contact with health professionals as needed. In addition to this the home had good links with the neuro rehabilitation consultant and people had on site access to therapy support.
People’s needs were assessed and care was planned and delivered in line with their individual care plans which described their needs, preferences and wishes well. We saw people and their loved ones had been involved in developing and reviewing these.
We saw positive relationships between staff and people who lived at the home, and staff communicated well with people who used non-verbal communication techniques. Staff knew how to respect people’s privacy and dignity.
There were effective systems in place to manage, monitor and improve the quality of the service provided. The home had an open and honest culture; staff told us they would be confident to report concerns, and the registered manager told us they were continually striving to develop and improve the service. Staff told us there was a strong focus by the provider about supporting people who lived at the home to have choice.
We found Fairburn Vale had a friendly, homely atmosphere. We saw people were well cared for and staff were welcoming and caring. We saw staff were particularly skilled in communicating with people and respected their privacy, dignity and independence.
We spoke with some of the people who lived at Fairburn Vale. One person we spoke said: 'Staff are friendly, I like it here'. Where people could not verbally express their views, we observed their care and signs of how their well-being was supported.
We spoke with three relatives of people who lived at Fairburn Vale. One said us: 'The care is absolutely excellent' and said 'Staff are superb'. One relative said her family member "could not be in a better place" and said they were happy with the care.
We spoke with the manager and two staff who told us they involved people as much as possible in order to provide care that was person-centred. Staff demonstrated a good knowledge of people's individual needs.
We saw most people enjoyed their food, although we noticed one person did not seem to enjoy the main course. We saw people had regular access to drinks and staff were aware of people's dietary needs.
We found staff were robustly recruited and vetted before they worked with people and there were systems in place to assess and monitor the quality of the service provision.
We spoke to people who use the service and they told us that they had been included in decisions about what care and support they received and when this would be available.
We spoke with two members of staff who were able to demonstrate a good understanding of the needs of the people who lived at Fairburn Vale. They told us that they were well supported by managers of the home and there were good opportunities for training.