Fair Haven Care 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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question was good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were clear systems in place to report and investigate all incidents, accidents, and complaints. Lessons were learnt to continually identify and embed good practice. Staff and leaders learnt lessons from incidents. Where people had an accident or incident, there were systems in place to assess what happened and what needed to be done to minimise it happening again. Staff understood the importance of reporting concerns and safeguarding issues, and notifications to CQC were made when required.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked well with people, families and healthcare professionals to maintain safe systems of care. They ensured continuity of care, including when people moved between services.

There were clear processes in place to support safe admissions, transfers and ongoing care. People, their families and relevant professionals were involved in assessments to make sure care was planned appropriately from the start.

Hospital passports and treatment escalation plans were in place to support safe transitions. These contained clear and detailed information about people’s needs, health conditions, medication and abilities. The hospital packs were kept up to date, and printed copies were stored in each person’s folder so they could be accessed quickly in an emergency.

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 concerns quickly and appropriately.

The provider had a clear safeguarding policy in place. Staff and managers had completed safeguarding training and understood how to raise concerns and who to report them to. People told us they felt safe and received care that met their needs. A relative told us, “Yes definitely, from what (relative) says to me I feel (relative) is safe”

Deprivation of Liberty Safeguards (DoLs) are an important part of the Mental Capacity Act 2005. They involve providers seeking legal authorisation from the local authority where they need to deprive people who lack capacity of their liberty.

DoLs applications had been submitted as and when required, with a log used to monitor applications, their outcome and when any reapplications were due. The registered manager understood the DoLs process and knew when an application would be required.

The provider submitted statutory notifications as required and had systems in place to identify, record and respond to concerns. The registered manager understood their responsibility under the Duty of Candour and promoted an open and honest approach when things went wrong.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were systems in place to assess, manage and monitor risks to people. Risk assessments covered key areas such as falls, nutrition and skin integrity. Risk assessments were used effectively to identify potential hazards. They were comprehensive, person-centred, and regularly reviewed.

Care plans were detailed and provided staff with clear guidance on how to support people safely and reduce the risk of harm. These were regularly reviewed to ensure they remained up to date.

Staff had access to people’s care plans and risk assessments and demonstrated an understanding of them. They had the skills and guidance to support people in a positive and appropriate way, including when individuals were distressed.

Systems were also in place to ensure staff received appropriate training and had the necessary skills and knowledge to support people safely.

The provider had systems in place to manage risks and maintain a safe environment, but these were not always fully effective. While most checks and safety measures were in place, some potential risks were not identified or addressed promptly, although action was taken when concerns were raised.

There were systems in place to monitor the safety and maintenance of the building and equipment. However, we found that not all wardrobes were secured to the wall, which posed a potential risk. This was brought to the attention of the registered manager, who took immediate action to arrange for them to be secured. A risk assessment was also completed promptly.

Equipment used to support people was easily accessible and stored safely when not in use.

The home was well lit, with clear signage and wide corridors that were free from hazards, supporting people to move around safely and independently.

A fire risk assessment had been completed by an externally accredited company. Although some issues had been identified, we saw that remedial actions had been completed in a timely manner to ensure compliance with fire safety regulations. Personal emergency evacuation plans (PEEPs) were in place, and regular fire drills had been conducted to ensure staff knew how to support people safely and effectively in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff on duty, and they were visible throughout the home. Rotas demonstrated that shifts were consistently covered. People told us they were happy with staffing levels and felt there were sufficient numbers of well-trained staff to meet their needs.
One relative told us, “There are staff there and the residents look happy. They all seem well looked after.” Another relative told us, “There are always people around the communal areas. If I need anything, there is always someone about.”

Staff were recruited safely and in line with safer recruitment procedures. New staff completed an induction and essential training to ensure they had the appropriate skills and knowledge for their role. Staff received ongoing support through supervision and appraisals, and good practice was recognised. A training and supervision matrix was in place to monitor compliance and ensure oversight.

There were clear arrangements for team working. Staff told us they worked well together and described communication within the team as effective.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had an infection prevention and control (IPC) policy in place which staff could access. Staff had received appropriate training and demonstrated an understanding of how to use and dispose of personal protective equipment (PPE), such as gloves and aprons. We observed staff following good hand hygiene practices and using PPE correctly to reduce the risk of infection.

The home was generally clean and free from unpleasant odours. However, some areas required improvement. We observed dust, cobwebs, and unclean corners in parts of the building. Cleaning arrangements appeared limited, with one housekeeping staff member working weekdays from 9am to 1pm, while weekend cleaning was undertaken by care staff. This was raised with the registered manager, who acknowledged the concerns and agreed to review staffing levels and cleaning hours immediately.

Relatives generally felt the home was clean and hygienic, with many describing it as well maintained. There was sufficient PPE and cleaning equipment available throughout the home.

The registered manager was aware of where to access relevant guidance, including infection control and outbreak management, and understood when to escalate concerns to external professionals such as Public Health and people’s GPs where required.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People were supported to make informed choices about their medicines. Where people had capacity, they were encouraged to manage their own medicines with appropriate supervision and guidance from staff. Risk assessments were in place to support this safely. Where people lacked capacity, decisions were made in line with best interest principles and were clearly documented.

The provider had a medicines policy in place, and medicines were managed safely. Regular audits were completed monthly, with actions taken to address any issues identified.

Staff had received medicines training, and their competency had been assessed to ensure safe practice.

Medicines were stored securely, including controlled drugs, which were only accessible to authorised staff. Storage conditions were monitored, including room temperatures. Liquids and creams with a limited shelf life were appropriately dated when opened.

Medication Administration Records (MAR) were completed accurately, and any refusals were recorded. ‘As required’ (PRN) medicines had clear protocols in place to guide staff.

We checked medicine stocks and found they matched the service’s records.

A relative told us, “[Relative] refuses medication regularly and they keep trying and they note down what’s happened.”