Fairmile Grange 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 inadequate. This meant some aspects of the service were not safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment and safeguarding.
 

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

People and their relatives told us they did not feel confident leaders and Fairmile Grange Care Home would address any issues they faced.

Incidents within the service were not recorded or reviewed to prevent reoccurrence. The manager informed inspectors staff always discuss incidents with the clinical team. However, records of accidents and incidents were not always complete, therefore themes or lessons learnt had not always been identified. For example, we identified records of incidents in the records of 7 people, we asked the leadership team to confirm what action had been taken. The manager told us, “No one told me about these, I would hope they were sent to the local authority safeguarding team and I’m sure the nurse on duty will have reported them.” Records showed action had not been taken. Incidents and accidents had not been discussed and were not know to the nominated individual. The nominated individual is responsible for the service on behalf of the provider.
 

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People and their relatives told us the service did not communicate well with other services to ensure people’s needs were known. Staff told us they did not know where to access information about people, and people’s care plans were not updated after a visit from an external health and social care professional, or hospital stay.

Health and social care professionals consistently raised concerns people’s needs were not being met. One health and social care professional commented, “Since the new management there have been more new admissions, often of quite complex or end of life patients. Sometimes I did get the feeling they were struggling to cope with all the needs. There have been a few times where I have asked for an action, and this has not been carried out.”
 

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

People told us they did not always feel safe living at Fairmile Grange Care Home. Comments included, “There are residents here who have bruises from where the carers push and pull them around, I try to be as independent I can.” And, “When the rough staff are on duty, you don’t dare ask them for help. They don’t talk to you and do it all in such a rush.”

The provider had a safeguarding policy and procedure in place; this was not being followed by staff or leaders which meant people were at risk of avoidable harm.

Not all safeguarding concerns had been reported to the local authority. Those that had often contained incorrect or incomplete information. Safeguarding referrals were not made or investigated in line with the providers policy. This meant there was a delay in preventing avoidable harm for people.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The manager had not made applications and did not have oversight of authorisations. Conditions in place were not recorded in people’s care plans and actions had not been taken to ensure care was delivered in line with legislation. Therefore people living at the service were being unlawfully deprived of their liberty.
 

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People did not have always have risk assessments in place, or had risk assessments which were out of date, therefore their health conditions or ability to contribute to completing care tasks were not considered. This meant people were not enabled to do things that mattered to them, and staff were not provided with sufficient information about how to support people safely.
 

The service did not detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Equipment, such as special mattresses used to prevent skin deterioration, were not consistently set in line with people’s assessed needs. We found 3 mattresses were incorrectly set and 2 were displaying ‘fault’. This had placed people at increased risk of avoidable skin deterioration. The service did not complete regular checks of the mattresses so could not be sure how long equipment was not being used correctly and there was a risk they would not have identified this shortfall.

During our inspection, concerns were raised by staff and relatives about fire evacuation procedures being unclear and the environment being obstructed. We shared these concerns with the local fire service who have attended the site. The provider also arranged for an independent fire safety review.

Managers ‘health and safety walk arounds’ had not identified furniture had not been secured to walls or people were at risk of entrapment. The service had not reviewed or taken any action following an incident where a person was able to leave the building without required staff support.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff told us they did not always receive support to ensure they could carry out their role. Comments included, “Supervision doesn't always happen on a regular basis due to managers being so busy. This leads to frustration as I don't have an opportunity to discuss any challenges or ideas I might have”, “To be honest, my supervision is due. It’s not a priority and there are lots of management changes, I’m sure it’s something they will look at soon”, “I keep my online training up to date or my shifts get cancelled. We all rush to do it.”

Staff consistently told us they work longer than their allocated shift time as there is not enough time to complete all tasks required of their role. We raised this with the leadership team during our inspection who stated, “Our staffing level is currently above the number of staff required for the home’s occupancy; however, staff were not always deployed effectively. We are reviewing ways to improve this, including looking at task allocations for washing up, activities and admin work. This will include giving nurses supernumerary time to catch up on paperwork.”

However, the service had a recruitment procedure in place. Recruitment records showed staff were recruited safely. This included an enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.
 

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People and relatives had raised concerns with the service about the level of cleanliness and told us they had not seen improvements. One relative told us, “There is not enough crockery or cutlery, so you see staff rush to rinse it off between the starter and pudding, often finding a stain from the soup or it has not been dried properly and is wet. It is very off putting.”

During our inspection, we observed oversight of infection, prevention and control measures were not always effective. Records confirming cleaning had taken place had not always been completed, and there were several instances where national guidance relating to the disposal of personal protective equipment (PPE) had not been followed. For example, we observed used gloves placed in open wastepaper bins in people’s bedrooms, ripped fabric materials such as soft furnishing and curtains which could not be cleaned properly, washing up left in and around sinks, and food stains in newly decorated areas.

A health and social care professional shared their observation of a person having a number of drinks left on their bedside table which had attracted ants. The provider was informed and commenced a deep clean of the bedroom.
 

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Improvements were being made to the way medicines were managed. However, this work was still ongoing, and further improvements were needed.

People received their medicines in a safe way. Two people told us they were happy with the way they received their medicines. We saw people were asked if they needed any medicines prescribed ‘when required’. Staff had training and competency checks to make sure they gave medicines safely.

A new system for managing medicines had just been introduced following some medicines errors and incidents. These errors and incidents had been reported, investigated and actions taken to try to prevent recurrences.

Guidance for medicines to be given ‘when required’ were in the process of being updated and improved, and this work had not been completed. Information was not available for some of these medicines or had not always been kept up to date if people’s doses or medicines had changed. When medicines patches were applied then these were recorded on patch charts, and the site rotated appropriately. However regular checks that the patches were in place were not usually recorded.

There were suitable arrangements for storing, ordering and disposal of medicines, including those needing extra security. Storage temperatures were monitored and were generally suitable.

Medicines care plans contained information on some higher risk medicines such as prescribed cream which may be flammable, to show that people’s individual risks had been considered. However, they were not in place for the risks associated with blood thinning medicines. The provider told us these would be put in place.

Regular audits took place which identified actions for improvement; however, they did not pick up some of the areas for improvement that we found.