Archived: Fallowfield House

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found '

Is the service caring?

This was a responsive inspection to previous noncompliance against the regulations and we did not look specifically at this area.

Is the service responsive?

This was a responsive inspection to previous noncompliance against the regulations and we did not look specifically at this area.

Is the service safe?

We found that the provider had put in place systems to check on the environment of the home and ensure that any work required was completed.

Is the service effective?

This was a responsive inspection to previous noncompliance against the regulations and we did not look specifically at this area.

Is the service well led?

The manager and provider had put in place a range of systems to check on the care provided at the home and the environment. We saw audits were carried out on people's care records to ensure they were up to date. Staff told us and records confirmed that processes were in place to carry out regular supervision sessions and yearly appraisals. The manager had in place a system to ensure that staff training was reviewed and up to date.

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found '

Is the service caring?

We saw evidence that people's needs were assessed and care was planned in line with assessed needs. There was evidence that professional advice and intervention were accessed to help maintain people's health and wellbeing. We observed staff delivering care and noted that they were patient and compassionate and supported people to be as independent as possible or addressed people's needs where they were unable to do so themselves.

One person told us, 'It's lovely here. The staff do everything they can to help you.' Another person told us, 'They have looked after me. They are always nice and kind to you. They always see me alright.'

Is the service responsive?

People's needs were assessed and their care plans reviewed and revised in line with the changing needs. People had access to a range of outside services to ensure their health and wellbeing was maintained including doctors, opticians and district nurses. We observed staff delivering care and found that they supported people appropriately and responded to people's individual needs.

Is the service safe?

We walked around the home and found that the premises were clean and tidy although some areas required some maintenance.

Staff we spoke with understood about infection control issues. Staff were able to talk about the need to use personal protective equipment (PPE), such as aprons and gloves. They were also able to discuss the need for good hand hygiene within the home.

Medicines were stored effectively and we witnessed staff dispensing medicines appropriately.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager told us there were currently no applications in relation to DoLS. The manager said they were currently considering the situation in light of the recent ruling on DoLS by the Supreme Court.

Is the service effective?

People's care records indicated that the provider involved other professionals and services to support people's needs. We saw people received treatments, such as antibiotics, in a timely manner.

It was clear from our observations, and from speaking to staff that they understood people's care and support needs.

Is the service well led?

The manager told us that she did review care plans but there was no formal recording of this. She also told us that she did not carry out any formal checks or audits in the home. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

There was no formal system in place to ensure that staff had up to date training. We were unable to reconcile staff training records and what staff told us about training. We saw there had only been three staff meetings within the past 18 months. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

We saw copies of minutes from joint meetings between staff, people who use the service and their relatives.

People told us their consent was gained prior to care being delivered and we found that staff acted in accordance with their wishes. Where people did not have the capacity to consent, we found the provider acted in accordance with legal requirements.

We found that people's care and support needs were appropriately assessed and their care was planned. They received care safely, and to an appropriate standard.

We looked at how the provider managed medicines and found there were appropriate arrangements in place for the safe administration, recording, obtaining, handling, storage and disposal of medicines.

We looked at the provider's recruitment process and found that this was robust. There was a structured selection process in place which aimed to ensure staff were suitably skilled, experienced and qualified to deliver care safely. Appropriate checks were conducted before staff began work to ensure people's safety.

We saw the provider had an effective complaints policy and procedure in place, which people were aware of.

At this inspection we found the provider had introduced new policies and procedures related to the management of infection risks and general cleanliness levels within the home.

Staff confirmed that new procedures were in place and these had been explained to them by the provider. We did not discuss cleanliness and infection control with people who lived at the home at this follow up inspection.

We found the provider had taken action since our last inspection to ensure that people were protected against the risks associated with a lack of cleanliness and infection control and improvements had been made.

However, although people who received care and support from Fallowfield House told us they were happy and we saw they were well supported, we found that failures to maintain cleanliness and manage infection control may put them and others, such as staff and visitors, at risk.