Fairburn Mews

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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.

Systems and processes supported the safe and effective management of accidents, incidents and complaints, although the recording of outcomes of some incidents was not always consistent. The registered manager maintained good oversight and responded appropriately to any complaints or concerns. Lessons learnt were identified and used to mitigate the risk of reoccurrence and drive improvements. Opportunities to share learning were cascaded with staff locally as well as in the provider’s other homes.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

People were safeguarded from the risk of abuse. The management team had effective oversight of safeguarding concerns and ensured these were reported appropriately. Staff had received safeguarding training and understood signs of potential abuse and how to respond to any concerns. The service was working within the legal framework of the Mental Capacity Act (MCA). People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Staff sought consent from people before they offered any support, and they understood the ways in which people communicated their consent.

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.

Risks to people’s health and safety were effectively, assessed, monitored and mitigated. For example, risks relating to safe smoking were considered, balancing people’s right to make their own choices whilst ensuring their safety. Positive risk-taking was an integral part of people’s care and enabled them to do things that were important to them. Where people’s abilities deteriorated due to their health conditions, staff understood the increasing risks, such as with mobility and safe swallowing, and helped them make informed decisions around their care and treatment. One person said, “Staff are all good at making sure I’m safe and they know I need to do things myself, they don’t try to take over.” One relative said staff managed risks well and told us, “They are on top of managing falls risks. There are proactive measures to mitigate the risks.”

Care records were detailed, up to date, and reflective of people’s current needs, risks and abilities. Clinical risks and people’s involvement were discussed at weekly meetings, daily huddles and in handover meetings, which meant staff had good information to support people safely. Regular reviews of people’s care and risk management took place in line with people’s changing needs.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

Safe and robust recruitment processes were in place and staff engaged in a supportive induction process to ensure they were prepared for their role. Staff turnover was low and there was a stable staff team who worked alongside people respectfully and did things with, rather than for them. The service retained consistent nursing staff. One relative said, “They have good staff retention. Lots of places have frequency of staff turnover. Here they have long term staff members, so they are obviously doing something right”. Some relatives felt there were not always enough staff at busy times of the day, although we were assured staffing levels were in line with people’s needs. Staff completed regular training relevant to their roles and the specific needs of the people living at Fairburn Mews. Staff engaged in regular supportive supervision meetings relevant to their roles and duties. The provider ensured expertise was available with the involvement of specialist staff such as physiotherapists and those with knowledge of particular health conditions, such as Huntington’s disease.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Medicines were mostly managed safely although some aspects of recording were not consistent or sufficiently detailed to ensure clear directions for staff. For example, protocols for medicines ‘as required’ sometimes had conflicting information with that in people’s medicine care plans. However, we were assured people were getting their medicines when they needed them.

Processes were in place for the timely ordering and supply of medicines. People told us they had their medicines on time. People spoke with staff about their need for medicines and staff worked with them to ensure their needs were met. Staff were alert to people’s non-verbal communication around pain and took swift action to ensure prescribed medicines were effective.

Medicine administration records were being used to record the administration of medicines and showed people were given their medicines as prescribed. Any errors were reported quickly and actioned accordingly.