Fairlight Manor

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 75 (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.

Following an accident or incident staff recorded what had happened and what immediate actions were taken. The provider then reviewed this. Staff told us accidents, incidents, safeguarding’s and complaints were discussed with the team as lessons learned to ensure they were all aware of any changes in care or practice and to reduce the risk of a reoccurrence. The provider told us they had responded to a recent incident by holding a no blame meeting with staff. This offered reassurance to staff involved and ensured learning was taken forward. Where appropriate the local authority safeguarding team and CQC were notified of any incidents.

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.

There was a procedure for staff to follow before people were admitted to the home. This included a pre-admission assessment, to meet the person and discuss their needs. This helped ensure people’s needs could be met when they moved into the home. This also ensured staff had the relevant knowledge and skills to support people safely. As far as possible family members were encouraged to visit the home before their loved ones moved in. One relative told us the staff were very professional, and this helped give confidence that the home was the right place for their loved one. The provider acknowledged that over time people’s needs may change and require more complex care such as nursing care which could not be provided at the home. They told us how any changes to care provision were discussed with relatives and relevant professionals to ensure any transition to a new service was managed safely and compassionately.

Hospital transfer forms were in place. These contained an overview of the person and their needs. This was sent with people if they were admitted to hospital so staff there had information about the person when they were not always able to communicate their own needs.

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.

There were systems in place to ensure people were protected from the risk of harm, abuse or discrimination. There was a safeguarding policy which was accessible to staff. Staff received safeguarding training and this was updated regularly. Staff understood the importance of safeguarding. They knew how to identify and report any concerns.

Staff told us in the first instance they would contact the provider or most senior staff member on duty. If this was not appropriate, they would contact CQC or the local authority safeguarding team. The provider told us they checked with staff during supervision that they knew who to contact and they ensured staff understood and retained their knowledge of safeguarding.

Relatives told us they did not have any concerns about their loved one’s safety, at this time. However, this was an issue they frequently considered because of media coverage around abuse in care homes. We discussed this with the provider who told us this would be something they were mindful of when talking with relatives.

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.

Care plans and risk assessments included guidance staff needed to help keep people safe. For example, some people had been identified at risk of falls due to their poor mobility. There was guidance for staff as to how this would be managed. This included the use of mobility aids and support from staff. We observed people being supported safely by staff when moving around the home. Some people had been prescribed blood thinners, these increase people’s risk of bleeding. Risk assessments contained detailed guidance about actions to take and support required to maintain people’s safety in case of a fall or accident.

There was information about how people may express themselves when they were distressed or anxious. The care plans included details of what may cause the person’s distress, how they may present, and actions staff should take to reassure and support the person.Discussions with staff demonstrated they knew people well and understood how to support them and ensure their safety. This included for example, checking people’s skin integrity when providing personal care and ensuring people were protected from the risk of malnutrition and dehydration.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There was a system to ensure the home and equipment was maintained and serviced. There were regular servicing contracts which included electrical safety and fire risk assessment. Regular checks took place to ensure a safe environment was maintained. There was fire, water temperature and window restrictor checks. Staff received fire safety training and fire drills were undertaken to ensure staff knew what actions to take in an emergency. Each person had a personal emergency evacuation plan to guide staff in case an evacuation was required at any time. There were regular checks of call bells to ensure people could contact staff when they needed them.

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.

Before the inspection, concerns had been raised with CQC about staffing levels. At the inspection we saw that people were supported by staff and attended to in a timely way. Staff told us that previously, on occasions, there had not been enough staff to support people. However, this had recently improved after discussions with the provider and there were enough staff working each shift. This was confirmed by the rotas we saw.

When staff started work at the service they completed a period of induction. This included a period of shadowing where they worked with more senior staff to understand the day to day running of the home and meet with people who they would be supporting. Staff completed an induction booklet, which was signed by them and a senior staff member as they completed each section. This included training, policies and observations of staff in practice, for example infection control and safe moving and handling.

There was a training program which staff completed. This was regularly reviewed and updated. Following training, staff completed knowledge checks to demonstrate their understanding. There was a supervision program and this allowed staff time to talk with the provider and identify any areas they needed support or wished to develop. One relative told us it was clear staff had a knowledge of mental health and dementia and this was their ‘forte.’

There were processes in place to ensure staff were recruited safely. This included references, employment history and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer.

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 home was clean and tidy throughout. Staff received infection prevention and control (IPC) training. Staff were responsible for aspects of daily cleaning. They understood their own roles and responsibilities related to the cleanliness of the home and the prevention of infection. Personal protective equipment (PPE) was available throughout the home and staff were observed to be using it appropriately. There were processes in place to prevent the risk of infection and maintain the cleanliness of the home. This included a daily cleaning schedule, and checks took place to ensure appropriate cleaning had been completed. Monthly infection prevention and control (IPC) checks were completed to further ensure cleanliness and protection from infection. The laundry arrangements were appropriate and segregated dirty and clean washing. This helped to reduce the risks of cross contamination.

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.

There were systems in place to ensure medicines were managed ordered, stored, administered and disposed of correctly. Staff had identified that during the warmer weather people’s bedrooms were too hot to store medicines safely. As an interim measure specialist cool boxes had been introduced, and medicines were safely stored in the provider’s office. Staff told us as the weather became cooler, medicines would be transferred back to people’s bedrooms. Only staff who had received medicine training and been assessed as competent gave people their medicines. Staff were knowledgeable about the medicines people had been prescribed. Medicine administration records (MAR) were completed when medicines had been given.

Some people had been prescribed ‘as required’ (PRN) medicines. There was guidance for staff about why these medicines were needed and how they should be taken. Where PRN medicines had been prescribed for people who may be distressed there were no details of how the person may display their anxiety or what actions staff should take before giving the medicine. However, staff told us this information was in people’s care plans. They also told us these medicines would not be given until they had been reviewed with the provider. The provider confirmed this was the process staff followed. The provider explained this ensured medicines prescribed for distress were only given when necessary. This helped to reduce the risks of people receiving their medicines inappropriately.

When medicines needed to be added to the MAR by staff the provider policy stated this should be checked by a second staff member. We identified an occasion where this had not happened. The provider took immediate steps to ensure the policy was followed.