Fairland House

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 that 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 Inadequate. At this assessment the rating has changed to Requires Improvement: This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to Good Governance.

This service scored 62 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The culture in the service was emerging with the manager having a sharp focus and high standards for their staff which were clearly communicated. Through increased observation and training the work force was strengthening. There were more robust recruitment processes to help ensure recruitment was undertaken and staff once employed were supported to provide person centred care and any shortfalls in care were addressed.

The provider had recently put in place inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Oversight and governance had improved with clear lines of accountability and external consultancy. The new manager shared the right values and work in cooperation with CQC and other regulators to ensure standards improved.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Complaints, suggestions and concerns were addressed and people given some opportunity to speak up. We found details on the complaints log needed to be more robust to ensure there was a clear audit trail of when and how concerns were responded to. The manager had developed audits to help them assess the care people received including night time audits, dining audits, daily risk meetings and walk arounds. The manager was visible in the service and staff said both the manager and deputy were approachable. The manager said they had been supported with their job role and was completing their probationary period.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had supportive mechanisms in place to support care staff and good recruitment processes. Staff were supported through policies which address employment laws to ensure staff were not discriminated against and were treated fairly at work.

The provider had implemented governance systems to manage and deliver good quality, sustainable care, treatment and support. We found however these were not yet fully effective to ensure people always receive good outcomes of care.

They had not always acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

The evidence we found supported a continued breach of Regulation 17 of the health and social care Act 2014: Good Governance.

Improvements were identified across the service. Whilst we were assured that the manager and their team were meeting people’s needs and there were systems and processes in place to monitor and improve the service, we felt progress had been slow. Previous management appointments had been unsuccessful, and the current manager had only been in post 3 months at the time of our assessment. Whilst they were making changes including focusing on recruitment and upskilling staff and improving care planning and changing people’s living environment, these improvements had only happened in the last few months. We noted staff supervision and appraisals were not fully up to date and staff said direct observations of staff practice were recently implemented. Regular use of agency staff made deployment of staff more difficult due to the levels of experience across the team and the high levels of dependency across the service, which included a high level of falls and unintentional weight loss. Staff feedback about levels of competency amongst agency staff varied.

The provider had employed a provider’s representative and outside consultancy for areas which had previously been identified by CQC and the local authority. Strengthening governance was resulting in improved outcomes for people using the service and relatives reported on improvements they had seen. However, we were made aware of 3 concerns from people recently using the service which did not assure us that recent improvements and quality systems were firmly embedded within the service.

Monthly provider audits were reviewed and showed actions were identified and an improvement plan was put in place. However, issues such as accident, incident and safeguarding reporting were identified as not being sufficiently collated, reviewed or escalated appropriately. There were also concerns that all but one care plan was out of date. Similar issues were identified by CQC as part of their assessment in January 2024.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other regulators to ensure that the service improved, taking into account previous CQC and the local authority quality monitoring teams findings. Improved governance had resulted in actions being identified but there were delays in embedding improvements as the previous manager left. The current manager has told us of their commitment to work in partnership with the deputy manager, the providers representative and external trainer and they were making improvements and strengthening the staff team in terms of numbers and competencies.

The provider was focusing on continuous learning, innovation and improvement across the organisation and local system.

At the last assessment we rated this service requires improvement and inadequate in well led. At this assessment we have identified improvements were been made since our last visit and no longer consider this provider inadequate. The local authority has also found improvements within the service. Although we still identified areas for improvement, we are confident that the manager once registered will continue to make improvements and we will seek additional assurances and a robust and updated improvement plan to monitor changes within the service to ensure people continue to have good outcomes.