Fairholme House

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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of 3 legal regulations in relation to people’s safe care and treatment, person-centred care, and good governance, due to inadequate care planning and risk assessments, environmental risks and governance at the service.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The registered manager told us they were committed to learning and improvement of the service. However, we found several concerns had not been identified as part of their quality assurance process.

The service had not been effective in identifying the areas of improvement in the home environment to reduce the risk of people injuring themselves.

Incidents and accidents had not been effectively and robustly reflected upon and used to drive improvement.

There was a lack of oversight and monitoring of incidents. Information was not clear, records needed to effectively detail, review and monitor incidents. It was not clear what action, if any, was taken following accidents and incidents. This meant opportunities to learn lessons from incidents and take appropriate action were missed.

Where people had fallen, incidents documented people were supported from the floor by two or three staff. There was no information about how people were supported from the floor, for example if any equipment had been used and there were no assessments or guidance in place for equipment. Staff when asked, were reluctant to expand on what this meant. This had not been identified by the registered manager to ensure staff were following safe manual handling practices.

People we spoke with did not always know who to go to if they had concerns. We heard “If I was worried about something I would tell my sons or daughters. I see them every day, I don't know who is in charge.”

People were placed at increased risks due to the lack of oversight and incomplete information.

The provider did not always work collaboratively with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The approach to identifying and managing people’s risks was not proactive or effective. Although there were systems in place to update people’s care planning and risk information, records had not always been updated to accurately reflect people’s needs. The registered manager did not review care planning audits to ensure any identified changes were made. This meant staff did not always have the information they needed to provide safe and effective care.

People’s care and support was not planned and organised with people, partners, and communities to ensure continuity. Staff and leaders did not always make appropriate referrals to healthcare professionals to ensure people received safe care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider did not always share concerns quickly and appropriately.

Systems in place were not effective at ensuring people were protected from abuse and neglect. Incidents were not reviewed and safeguarding concerns were not always recorded. We did not receive evidence to show how people were supported and what action had taken place to keep people safe.

We were not always notified about safeguarding alerts by the service. Where we had been made aware, this was not always reflected on the services safeguarding log in order to monitor and mitigate the risk.

Policies in place to safeguard people, did not always have links or details of who to contact so staff could raise concerns. Staff we spoke with were unaware of how they would raise a safeguarding concern.

People provided mixed feedback when asked if they felt safe. Some people told us they felt safe and well looked after, however we also heard there was a limited number of staff available which contributed to some people feeling unsafe.

People were put at risk of harm due to the lack of staff understanding and robust safeguarding procedures.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Risks associated with people’s care had not always been identified or managed to ensure people received safe care. There was no risk assessment in place for people who required support around allergies, refusing personal care, equipment, and skin integrity.

Several people had lost weight over the past 6 months. Systems in place to monitor and record people's weight had not been effective in identifying the risks and actions required for these people. We shared our concerns with the registered manager who spoke to staff. Staff had not been clear on how the care planning system worked as they had not received any training. There was no oversight to check the quality and accuracy of risk assessments.

Information and guidance were not available to support staff with managing peoples care safely as risk assessments did not always reflect people’s current needs. For example, risk assessments in place for people who required support to manage their diabetes did not provide enough guidance, information or action on how to mitigate the risk to keep people safe.

People were not involved in their care planning. People we spoke with told us “I'm not involved in planning my care routines.”

People were at risk of harm from the lack of risk assessments, staffs limited understanding of risks and the failures in robust quality monitoring.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities, and technology supported the delivery of safe care.

Stairways were unlocked and contained equipment which put people at risk of using stairs unattended. Doors containing chemicals and electrical hazards were unlocked, and there was mould visible in the dining room.

The staff office was open and accessible to anyone in the home, cabinets containing people’s personal details were unlocked.

People’s bathrooms and communal bathrooms were inaccessible for people to use as they contained boxes, broken facilities, and equipment. One person’s fire door was propped open with a chair and would not have closed in the event of a fire.

Although weekly checks of the fire alarm system had taken place, the service had not carried out fire drill evacuations in the last two years. Where professionals had identified the need for further equipment such as additional smoke detectors, the registered manager had not taken action to address these safety concerns. Health and safety audits were incorrect in identifying concerns found during the inspection, and did not contain any actions. The registered manager told us they would take action to address these concerns following the inspection.

This put people at increased risk of harm due to a failure of effective oversight.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff did not always work together well to provide safe care that met people’s individual needs.

People we spoke with told us they had some concerns about the level of staffing. We heard "I would like to come out my room. I'm waiting for the staff to take me to the lounge, but I have to wait" and "I don't think the staff are well trained. I don't think there are enough staff. I don't think there are enough staff at night or the weekend"and “Sometimes the staff are dealing with me, and they just go off and deal with someone else.” However, we also heard "The staff work well together and are well trained."

The training matrix identified staff were not trained in care planning and risk assessing, incident and accident recording and supporting people with modified diets. Not all staff were trained to administer medication.One member of staff was missing from the training matrix. Some staff were allocated time within working hours to complete their training; however not all staff were aware of this as it had not been communicated to them.

Safe recruitment practices were not always followed. Staff files did not include evidence the service had carried outDisclosure and Barring Service checks [DBS] or interviews. Following the inspection, we were sent evidence of DBS checks.

We were not assured all staff received supervision as oversight in place did not contain all staff names. Supervision documentation did not contain information about what was discussed or action taken by the registered manager to address concerns raised, some of which could be considered a safeguarding concern.

People were put at risk from inappropriately trained staff.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During the inspection, staff supported someone in their room with personal care. Staff did not take off their gloves when leaving the room and accessing the office. Staff did not wear personal protective equipment (PPE) appropriately during mealtimes. Equipment such as masks, were visible in the corridor, these had expired 2 years ago.

The provider had not been effective in identifying areas of improvement in the home as there were inadequate checks in place. Audits for infection prevention scored some areas as a zero indicating there were improvements to be made, however there were no supporting comments or actions to ensure these areas were followed up on.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff did not always involve people in planning.

People told us "The staff bring the tablets round in the morning and lunchtime they could do with more staff" and "The staff doing my medication. They [staff] tell me when they're coming."

Policies in place around medicines were not clear on staff responsibility or action to take. There were no medicine competency checks in place to ensure staff were competent to administer medicines safely.

The provider checked medicines into the home, ensured stock checks were correct and in line with current regulations, however we found medicines due to be returned had not been stored correctly.

Care plans did not include information for people’s needs around creams or PRN [when required] medicines. Where people had limited capacity around medicines and the need for PRN, there was no supporting documentation in place to enable the service to make the decision on their behalf.

Staff provided good information about why people might need PRN medicines. However, staff we spoke with told us “There is no place to record why people need PRN medicine, if they wanted pain relief, we would handover why they needed it to the shift,” and “PRN protocols are in place to say why they are taking PRN medicines, but we do not write a reason why they need it.” Care notes did not document the reason why PRN medicines were needed or requested.