Fairfield Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

This service scored 36 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Feedback from staff highlighted conflicting viewpoints and a lack of consensus within the team. Leaders had not established a shared vision, values, or consistent direction for staff. People and staff were not always involved in decision making, implementing systems or included in improving the service. While some staff told us they felt comfortable raising concerns and sharing suggestions, others said they did not feel encouraged to express their views or contribute ideas for improving the service. Staff did not have all the information they needed to provide for people’s current needs. People did not always receive their preferred options. One person’s care plan contained dismissive language and failed to recognise underlying distress, frustration, or unmet needs. We found institutional practices that undermined dignity and culture. For example, some staff referred to people by their room numbers, which was impersonal.Leaders told us they had identified and addressed this issue with staff through meetings and daily walk rounds to reinforce standards of dignity and respect, and they continue to encourage feedback from staff, people, and relatives.

The provider did not always have inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. We found systems in place were not always effective which led to a lack of oversight of people’s care plans and maintaining a safe environment. Leadership structures and audits existed, but they were not always effective in ensuring high standards of care or addressing recurring concerns. Our review of care documentation highlighted significant contradictions and gaps which leaders had failed to identify or act upon. For example, one person’s care plan stated both that they had good eyesight and poor eyesight, and their personal history section was sparse. Some members of staff told us they felt supported by both the home manager and deputy manager. One staff member described the home manager as “Fair and approachable at all times.” However other members of staff we spoke with told us they felt “intimidated”, and “fearful,” of management. Feedback from relatives we spoke with was mixed. Some relatives described managers “Approachable” and “Visible”, however others experienced inconsistency due to leadership changes, with some relatives not aware a new manager had come into post at the beginning of the year.

People did not always feel they could speak up and their voice would be heard. There were processes for raising concerns and providing feedback. The provider had information in place for people and for staff on how to raise concerns, including complaints and whistle blowing policies. Some people and their relatives told us they felt able to raise their concerns. One relative said, “They consider what we say, and we do ask questions if we think something is amiss.” However, another relative told us their loved one felt hesitant to speak up, as they had previously raised concerns but felt that no action had been taken.One person told us they had repeatedly raised privacy concerns, but nothing had been done. When we brought this to the provider’s attention, they acted immediately to rectify the situation. Some staff told us they feel comfortable raising concerns and are supported in doing so. However, other staff members described a culture of fear, where they were afraid to raise concerns. One member of staff told us, “Staff are afraid to voice things as we are shouted at.” Another staff member stated, “I am petrified to go and see them [management].”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked with them. Leaders told us their staff were very important to them. There were procedures in place to consider staffs’ individual needs, this included considering staff’s diverse needs and ensuring all staff were treated equitably.  A cultural representative initiative had been introduced to help promote inclusion. Cultural diversity within the staff team was positive.However, some staff told us they did not always feel they were treated fairly when raising concerns or when workload tasks were being allocated across the team.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. We found governance systems were neither accurate nor reliable in monitoring safety, documentation, or risk. Although audits initially appeared regular and structured, they failed to identify issues observed during this assessment, such as conflicting information within care plans. There were issues in record-keeping, including missing or inaccurate care documentation. Care plans showed signs of template-based completion such as repeated phrases, contradictory entries, and lack of clarity. Issues across health and safety and infection prevention control (IPC) were not addressed through existing audit processes. Medication audits failed to detect discrepancies in medication records and unsafe storage. Emergency preparedness and evacuation plans were found to be insufficient. Evacuation plans lacked clear instructions. Relatives told us about leadership turnover impacting continuity. Comments included, “I don’t really see the manager I think there have been several managers in the few years,” and “They change so often, but I think it’s [Name of a previous home manager], but I might be wrong.” We found there had been 3 different home managers in post within the last 3 years.

The provider understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement. Professional partners described effective communication and partnership working with the providers leadership team. The new home manager, regional manager, and deputy were all noted to have engaged proactively, contributing to a strong working relationship with the local authority contracts and quality team.

The provider did not always focus on continuous learning, innovation, or improvement across the organisation or the local system.While some quality assurance and monitoring processes were in place, they were not fully embedded into practice, limiting their effectiveness. Issues such as inconsistent care documentation, poor infection control, and unresolved regulatory breaches from the previous assessment indicated that learning was not routinely leading to meaningful service improvements. Some staff reported feeling unsupported, which affected the development of a blame-free culture and limited opportunities for reflective practice and professional growth. There was little evidence that the provider engaged with research or ensured that practices reflected current best practice. Ongoing concerns, including unsafe PEEPs, unaddressed environmental hazards, poor hygiene despite completed cleaning records, reliance on generic care plans, and repeated use of contradictory or incomplete care records, demonstrated that learning from previous assessments and internal audits had not been embedded.