Fairview Court Care 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 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 good. At this assessment the rating has changed to requires improvement. This meant governance was inconsistent and not always effective to monitor the quality and safety of the service. The service was in breach of legal regulation in relation to good governance.

This service scored 61 (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. Staff and leaders promoted a positive culture and were committed to providing a quality service to the people they supported. The registered manager was supported by the provider, and staff spoke positively of the leadership team and their roles within the service. The provider demonstrated respect for people’s human rights and valued diversity within the organisation. A staff member said, “I get a lot of support from the registered manager; we have a very good rapport.” Another staff member described how a group of staff with an interest in gardening had recently been working together informally to improve the outside space. A staff member commented, “Happy residents and happy staff. Staff morale is good.”

The provider had 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. The service had an established registered manager in post who demonstrated their knowledge and experience of both the service and the people supported. People and their relatives were familiar with the registered manager and confirmed they maintained a visible presence. A relative said, “I talk to the manager she comes around.” Staff spoke positively of the support they received. During our site visits, managers from the provider were present and engaged in the assessment process. They were open and transparent regarding recent shortfalls identified and were open to challenge.

The provider fostered a culture where people felt they could speak up and their voice would be heard. The provider had procedures to support staff in raising concerns and contacting external agencies when necessary. Staff confirmed there were processes such as surveys, supervision and staff meetings to help them raise any issues. A staff member said, “There is a survey, we have team meetings and also supervisions. I am comfortable to speak up.” Staff told us the registered manager was supportive and approachable, and they felt confident their concerns and would be listened to and addressed. A staff member said, “[The] registered manager is approachable. She is fair and makes you feel an important part of the team."

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 explained how they supported the diverse needs of staff, including those with protected characteristics. This included recognising and supporting individual staff members religious beliefs, sexuality and learning needs. Staff had access to equality training to support their understanding of protected characteristics and awareness of bullying and harassment. Staff told us the registered manager was approachable and had responded appropriately when any concerns were raised.

The service did not always have clear and effective governance, management and accountability systems. They did not always act on the best information about risk or share this securely with others when appropriate. The provider was conducting a series of service level and provider level audits to monitor the quality and safety of the service. However, these audits were not always effective. The provider had recently identified shortfalls in governance processes, which placed people at increased risk of harm. The provider identified the concern following an internal investigation and in response was taking action to review risks and improve governance processes. Despite this response, the incident showed the service’s existing processes had not prevented the shortfalls from happening in the first place. The concern had not been referred to the local authority safeguarding team, during the assessment we identified several other incidents which had not been notified to CQC as required. Governance processes were not effective in identifying and addressing issues we found, including gaps in behaviour monitoring records, assessing the compatibility of people’s needs, and ensuring safeguarding concerns were appropriately referred to the local authority and CQC. The provider responded promptly during the assessment, sharing evidence of actions taken to address shortfalls identified. Following the assessment, we received an update detailing the provider’s progress against their improvement plan.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The provider described how they worked in partnership with professionals such as GP, mental health and the speech and language therapy teams to meet the diverse needs of people. Records showed the service made appropriate referrals and involved external professionals when needed to support people’s care. People were supported to access health services as required. Feedback from professionals who worked with the service was mixed. Most professionals spoke positively of care staff and the registered manager. However, some professionals raised concerns about difficulties engaging with the service and individual staff. The provider stated they had taken steps to address this and acknowledged some strained relationships with professionals; they expressed a commitment to reset working relationships to ensure the service operated effectively in partnership.

The provider had not always focused on continuous learning, innovation and improvement in the service. Following shortfalls identified, we were informed the service had been focused on resetting aspects of delivery and implementing changes. Processes intended to share learning with staff were not always effective. Further work was needed to embed improvements and establish a consistent culture of learning, innovation and improvement. The provider showed an understanding of how to improve the service and had responded promptly to recent concerns. Staff had been invited to share feedback, and additional training had been arranged to improve staff skills and competence. The service had developed an improvement plan and the provider’s managers, and quality team were based at the service to help ensure progress was made. People, relatives and staff told us communication with the management team was positive. The provider had systems to involve people and their relatives and gather feedback. The registered manager explained they took part in provider forums and connected with managers across services to support learning and innovation.