Fairfield Nursing Home

On this page

• 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

Safe – this means we looked for evidence people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. We found incidents and complaints were investigated through an escalation process and root cause analysis was conducted to improve safety. Leaders told us staff were encouraged to speak out through an open-door policy and escalation pathways. Professional partners confirmed safeguarding and care concerns are discussed during contract meetings, with lessons learned and actions agreed. However, feedback we received from staff was mixed. Some staff members told us they felt their concerns have been heard by management and the provider is actively taking steps to respond to staff feedback. However, other staff members told us they did not feel able to speak up for fear of reprisal and when they did try to voice their concerns they were not taken seriously or acted upon. Some people and their relatives said they felt able to raise concerns. However, some people we spoke with told us they have tried to raise concerns previously but no longer feel there is any point in doing so.

The provider did not always manage or monitor people’s safety or make sure there was continuity of care. Systems and processes designed to keep people safe were not always effective. Records and practices contained contradictions and omissions which meant safe systems and pathways of care could not be assured. A sample of care plans we reviewed were inconsistent and not robust enough to enable unfamiliar staff to provide safe and effective care. Some staff told us care plans lacked sufficient information and did not reflect people’s needs. They described handovers as disorganised and ineffective. Some members of staff reported the electronic recording system often failed to capture information accurately, and there was no effective managerial response to address these concerns. We found evacuation arrangements were not sufficient to meet the needs of people. This meant there was a risk staff would not have the information required to carry out a timely and safe evacuation. We reviewed a sample of Personal Emergency Evacuation Plans (PEEPs) and all lacked practical detail and contained contradictions, including around people’s mobility, consent and staffing levels. Staff were not provided with clear instructions and escalation protocols to ensure safe evacuation in emergency situations.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared safeguarding concerns to the appropriate agencies. The management team confirmed a commitment to continuous safeguarding training and robust incident reporting. We found procedures were in place to identify and address safeguarding issues, enabling timely action. Staff told us they had received safeguarding training. Most people we spoke with reported feeling safe in the home. Comments included, “I am 100% safe,” and “I feel safe.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care plans lacked personalised strategies for managing refusal of care or distress, with vague instructions without specifying timeframes or escalation steps. There were also inconsistencies in how risks were documented and addressed. For example, one person’s fall history was not adequately reflected in their care planning, and another person’s safeguarding status fluctuated between “low risk” and “extreme risk” without clear rationale. While risks were recognised, people were not always actively involved in understanding or managing them in a way that promoted autonomy or supported their preferences and wellbeing.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. We found evidence of unsafe practices. Several environmental concerns were observed that could impact the safety and well-being of people. We found multiple safety hazards including unsecured wardrobes and trip hazards from trailing wires. Power tools were left out and accessible in the garden. Storage areas including cupboards and laundry rooms were found unlocked and contained hazardous materials. One storage cupboard door had a faulty lock and handles. One person had a cracked sink in their bathroom, and another person had a broken toilet seat. Bins with sharp broken pedals were left in people’s rooms. A freshly mopped floor was left without appropriate signage, creating a slip hazard. We found there was not enough evacuation equipment to meet people’s needs. This meant there was a risk staff would not have the resources required to carry out a timely and safe evacuation.

The provider did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. We found the system used to work out how many staff are needed does not fully reflect the actual support people. We observed staffing levels were insufficient to safely and effectively meet the number and complexity of people’s care needs. Some staff we spoke with told us the home was short-staffed, leaving people’s needs unmet. One staff member told us they feel there are sometimes not enough hours to complete tasks during their shift. One member of staff commented, “Staff are run off their feet and do not have time to talk and listen to people they are supporting.” We found staff were up to date with mandatory training and staff including agency staff were inducted appropriately. One staff member said, “I feel I had an in-depth induction and training.” Another commented, “I have learned a lot of new things and management have supported me all the way through.” Some people and their relatives told us they were familiar with regular staff and noted occasional use of agency staff. However, one person we spoke with told us, “There are lots of changes, more staff of a day than a night but I always get help when need it.” A relative stated “There is always someone on the floor but at weekends there doesn’t seem to be as many staff on.” Most relatives praised staff for their professionalism, attentiveness, and ability to manage complex needs. One relative said they appreciated “Staff introductions and their courteous behaviour."

The provider did not always assess or manage the risk of infection effectively. We found multiple breaches in hygiene and cleanliness standards. Dirty equipment such as wheelchairs, hairbrushes, toilets, and commodes were found throughout the home, alongside visibly soiled pillowcases and bed sheets. PPE was frequently mismanaged, left in people’s drawers, disposed of in general waste bins, and in inappropriate places such as cigarette ashtrays. Cleaning records were ticked daily but did not reflect the actual cleanliness we observed. One staff member stated, “Staff know to wash hands and use PPE, but PPE is not consistently worn.” We observed some staff were wearing PPE appropriately, however, others were not. We found the door to the sluice room was left unlocked on multiple occasions posing a potential infection control and safety risk. Mould was found in one person’s drink bottle, and many jugs of water and juice left in people's rooms were not labelled with a date, posing a risk of contamination. Feedback we received from people and relatives was mixed, with some expressing concerns about hygiene and others describing the home as clean.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. We found several concerns around how medicines were handled. Medicines were found in the rooms of people who did not self-administer, and one person had not received their prescribed medicine for several days. Records showed medicines requiring patch rotation were not always applied or recorded correctly, which increased the risk of skin irritation and exposure to unsafe drug levels. Covert medicines were being administered in ways that did not match authorised instructions, and there was no clear evidence that time gaps between doses were consistently followed. Topical medicines were not managed safely. Steroid creams were not always applied as prescribed, and there were no records showing how or when other creams were used. PRN (when required) medicines were not consistently supported by written protocols, meaning staff did not always have the necessary guidance to ensure these were administered safely and appropriately. Care plans contained inaccurate or outdated information about medicines, including medicines no longer prescribed, or support needs which had changed, creating a risk of unsafe administration. The use of emollient creams was not risk assessed in relation to fire safety. Medicines administration records (MARs) did not always contain correct allergy information, with one person’s MAR recording no known allergies, while their care plan documented an allergy to a medicine. Some members of staff told us time-specific medicines were not always given at the correct times, supplements were administered without proper authorisation or recording, counts were often inaccurate with medicines missing or overstocked, and expired homely remedies were still being stored. One member of staff told us: “Prescribed creams are being removed from residents’ locked cabinets and stored in the clinic room. We are unsure whether these are being applied as required.”