We carried out a review of the data available to us about Fairhaven Care Home 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 Fairhaven Care Home, you can give feedback on this service.
Fairhaven Care Home is a care home which accommodates up to 21 people in one adapted building. Fairhaven Care Home is registered to provide accommodation and personal care for adults with dementia or physical health and support needs. At the time of the inspection there were 19 people living at the service.
People’s experience of using this service and what we found
People were happy living at Fairhaven Care Home and spoke very positively about the care they received.
Recruitment practices were effective and there were sufficient numbers of staff available to meet people's needs in a safe and unhurried way. People were protected from avoidable harm and individual, environmental and infection control risks were managed appropriately.
People received their prescribed medicines as required. There were safe arrangements in place for obtaining, storing and disposing of medicines.
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.
People's care plans and risk assessments contained detailed information about them and their care and support needs. This helped to ensure staff delivered care that was individual to each person.
The service had a positive person-centred culture. Both people and staff told us the management team were approachable. The service worked in partnership with other agencies to aid joined up, person centred care provision.
Effective quality assurance systems had been developed and implemented to continually assess, monitor and improve the quality of care people received.
The management team were open, approachable and supportive. Everyone was confident they would take action to address any concerns promptly.
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 16 March 2021).
Why we inspected
This was a planned inspection.
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.
We undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect it. Ratings from previous comprehensive inspections for these key questions were used in calculating the overall rating at this inspection. Please see the safe and well led sections of this report.
The overall rating for the service has not changed and remains Good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Fairhaven Care Home 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.
We found the following examples of good practice.
There were procedures in place to support safe visiting by family members or professionals. Staff undertook screening of all visitors including temperature checks and a questionnaire to determine risks posed by visitors. Rapid response lateral flow tests (LFT) were undertaken for visitors before they entered the home. Visitors were provided with Personal Protective Equipment (PPE) and guided to its safe use. A separate room accessed via an external door was available for family visits.
New admissions to the service were supported in line with best practice guidance. All new admissions were expected to provide recent COVID-19 test results, were further tested by the service following admission and isolated upon arrival for 14 days to minimise the risk of potential infection to existing people. These procedures were also followed when existing people returned to the home following a hospital stay.
Staff had undertaken additional training to administer insulin meaning there was a reduced need for community nurses to attend the home should there be an outbreak within the home or high levels of Covid-19 in the local community.
The home supported people living with dementia and had considered and assessed the mental capacity of people to agree to regular Covid-19 testing and immunisation. Where necessary these decisions had been made in people’s best interests following consultation with relevant people.
People and staff were regularly tested for COVID-19. Staff had LFT testing twice a week as well as standard Polymerase Chain Reaction (PCR) tests weekly. The registered manager understood the actions they needed to take should any tests return a positive result.
The service had a good supply of PPE to meet current and future demand. Staff had received training in its correct use and disposal. Staff had also received training in infection control practices and individual risk assessments had been completed for staff members who may be more vulnerable due to pre-existing health conditions.
The home was kept clean. Staff kept detailed records of their cleaning schedules, which included a program of frequent cleaning of high touch surfaces, such as light switches, handrails and door handles.
Fairhaven is a residential care home that was providing personal care to 21 people aged 65 and over at the time of the inspection. People living at the home had a range of care needs, including people living with dementia.
People’s experience of using this service:
• At the last inspection in December 2017 we found risks to people were not always effectively managed. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and provider was required to make an action plan for improvement. At this inspection we found improvements had been made and there were effective systems in place to respond to incidents, which included reporting to the local authority where appropriate.
• At the last inspection we also identified concerns around the homes governance, and found systems did not ensure the quality and safety of the service was assessed, monitored and improved. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and we told the provider to take action. During this inspection we found quality assurance was effective, and the registered manager completed regular audits to identify concerns and drive improvements in the quality of care delivered.
• Risks to people and the environment were effectively managed though robust assessments and people were appropriately protected from the risk of abuse and avoidable harm.
• People and relatives told us they were happy with the care and support provided at Fairhaven.
• People were supported to receive personalised care to meet their needs and care records were person-centred to reflect people’s likes, dislikes and preferences.
• People and relatives were involved in the planning and delivery of their care, and the registered manager sought regular feedback from people.
• People were supported to receive their medicines safely and in a timely manner by staff who were appropriately trained for their roles.
• People’s rights and freedoms were upheld and staff treated people with dignity and respect.
• People were encouraged to make their own choices and decisions as appropriate, and where people required additional support with this staff followed best practice guidance and legislation to support them.
• People had access to a range of activities to meet their interests, which were flexible to meet their individual needs.
• The service met the characteristics of Good across all areas. More information can be found to evidence this in the full report.
Rating at last inspection:
This service was previously rated as Requires Improvement at the last comprehensive inspection. This report was published on 22 February 2018.
Why we inspected:
This was a planned inspection based on the previous inspection rating.
Follow Up:
There is no required follow up to this inspection. However, we will continue to monitor the service and will inspect the service again based on the information we receive.
This is the first inspection since Oakray Care (Fairhaven) Limited was registered to provide the service in June 2017.
This inspection took place on 14 December 2017 and was unannounced. We returned on 21 December 2017 to complete the inspection.
There was a registered manager in post at the service. 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 and associated Regulations about how the service is run.
The systems for responding to incidents and reporting to the local authority safeguarding team were not always followed effectively. The registered manager was not aware of some incidents that had happened and action had not always been taken to review the care provided to people to minimise the risk of incidents happening again.
On the first day of the inspection we found that the systems to identify and manage other risks people faced were not always effective. Action had not always been taken to ensure staff had clear information about how to minimise the risks to people. By the second day of the inspection the registered manager had taken action to address the concerns regarding risk management.
On the first day of the inspection we found decisions taken on behalf of people who did not have mental capacity did not always follow the principles of the Mental Capacity Act. By the second day of the inspection the registered manager had taken action to ensure they met their legal responsibilities when making decisions on behalf of people.
Whilst the registered manager had taken action following the first day of the inspection, action was needed to ensure the improvements were sustained and embedded in practice.
The governance systems were not effective at ensuring the provider met their legal obligations and the service made any necessary improvements. Oakray Care (Fairhaven) Limited had been the provider of the service since June 2017. The registered manager reported that visits to assess the service by one of the directors of Oakray Care (Fairhaven) Limited had taken place on several occasions, but they had not received any feedback from the visits. The registered manager was not aware whether there were actions they needed to complete following the visits.
The registered manager completed a number of internal audits in the service. However, these audits had failed to identify the concerns identified in this inspection. The governance systems did not ensure the quality and safety of the service was assessed, monitored and improved.
People who use the service and their relatives were positive about the care they received and praised the quality of the staff. Comments from people included, “Without a shadow of a doubt they look after [my relative]. She wouldn’t be with us unless she lived here”; “Staff are very good. They have looked after [my relative] extremely well” ; “I have been very happy with the care provided”. We observed staff interacting with people in a friendly and respectful way. Staff respected people’s choices and privacy and responded to requests for assistance.
People told us they felt safe when receiving care and were involved in developing and reviewing their care plans. Medicines were stored safely in the home and staff had received suitable training in medicines management and administration. People received the support they needed to take their medicines. There were sufficient staff available to provide safe care.
Staff understood the needs of the people they were providing care for and had the knowledge and skills to meet their needs. Health and social care professionals who had contact with the service were positive about the care people received and skills of staff. Comments included , “Staff ask for help when appropriate, but when they do they have already tried a number of options and come with relevant information”; “Staff always liaise with me if they feel a resident needs extra input and they are always open to new ideas” and “The home manages people’s complex needs very well”.
Staff received a thorough induction when they started working at the home. They demonstrated a good understanding of their role and responsibilities. Staff had completed training relevant to their role, which they said was good and helped them to meet people’s needs.
People had regular meetings to provide feedback about their care and there was an effective complaints procedure. People enjoyed the group social activities that were arranged.