Fairfax Manor 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. This is the first assessment for this newly registered service. This key question has been rated 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.Staff felt there was a learning culture with a drive for improvement. Where there had been an accident or incident, leaders used this as a learning opportunity to understand how a repeat of the incident could be avoided in the future. Learning was shared with the staff team during handovers, supervisions and memos. Staff felt confident they could raise an issue and this would be listened to. One member of staff told us, “I know the managers would act upon a concern I had.”

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 joined up approach to working with health care staff. The GP visited each week and in advanced of this, staff would identify people who would benefit from a GP review. Staff knew people well and were confident in handing over information to visiting professionals. Leaders worked with health and social care organisations, such as hospitals and the Local Authority, to support people to be admitted to the service in a timely way.

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.Staff felt confident in escalating a concern of abuse or neglect. Staff were trained in safeguarding and understood their role in recognising potential signs of abuse. Leaders worked in close collaboration with the Local Authority and CQC to report safeguarding concerns. There was one instance where a safeguarding allegation was not notified to CQC, however, this was resolved during the inspection. People felt safe living at the service. People told us, “I feel safe here, the speed the staff respond is very good.” And “I think it is very safe. There is a calm atmosphere.”

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.People were involved with decisions to manage their risks. People were consulted and fully involved with the creation of risk assessments. There was an approach of positive risk taking to ensure people were not restricted and prevented from doing things which were important to them. For example, some people routinely left the service to access their community independently. Staff and leaders had a document in place which could support the police in finding the person, should they get lost. Risk assessments were clear and guided staff to support the person in the way they wanted.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.The environment was decorated and finished to a very high standard. People’s rooms were personalised and adjusted to meet their care needs. The standard of cleaning was also to a good standard and people noted the service was always kept clean. One person told us, “There is always a cleaner around.” And “It is kept nice, clean and tidy.” Environmental checks, such as fire safety and electrical safety, were all completed within the set timeframes. We found the first floor which supported people living with Dementia needed more dementia friendly signage. For example, whilst some people’s room had their name on it, this was not the case for everyone. Signs had not always included consideration of use of colour contrast which may impact people’s ability to navigate their way around. We have not identified impact for people however the provider told us they intended to ensure they operated within current best practice principles around dementia environments for the first floor.

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.We found there were enough staff. We found response times were prompt and there was consistent staffing, however, there was mixed feelings about this amongst the staff group. One member of staff told us. “Managers say there are enough staff but I don’t think that’s possible. There aren’t enough staff.” While another member of staff said, “There are enough staff. We are busy but we are fine. We manage”. This was also the case when we spoke with people. Comments included, “Yes, there are enough staff.” And “There are enough people around. There are separate staff serving food, serving coffee and cleaning.” While other people said, “They could do with more staff.” And “There are not enough staff, you have to wait a long time.” We discussed this with leaders who were confident there were enough staff and they intended to work with people, relatives and staff to explore any concerns they may have around staffing. We found staff were trained in all of the key areas to provide safe care.

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.We found staff consistently managed the risk of infection transmission. Staff were trained in infection, prevention and control and had access to personal protective equipment (PPE). Leaders worked with local infection control teams to manage the spread of infections to promote people’s health and wellbeing.

While the provider made sure that medicines and treatments were safe and met people’s needs, improvements were needed in some areas. We found medicines were administered correctly with staff being kind, attentive and caring. Competency checks were being completed to make sure staff have the right knowledge. For some documentation, instructions were not always accurate for the tasks are doing. For example, the GP instruction for one person was to apply a cream to their legs but staff were applying this all over the person’s body. We also found thickener which should have been on the medication record, but it wasn’t. We also found for people who wore medicated patches, the documentation needed to be clearer on where the patch was applied last time. However, we found no one had been negatively impacted and the provider confirmed they would address these issues promptly.