Fairmile Grange 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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement: This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.
 

This service scored 46 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

People and their relatives told inspectors the service is not always well-led. The service did not have well developed statements of its vision and values. This meant staff were not always aware of the expectations of the provider.

Feedback about the atmosphere and culture of the service included, “There needs to be more management, supervisory staff. There often seems staff are not guided and led. There also needs to be management at weekends as there is zero”, and, “The wellbeing team are just great, and we cannot fault them, but they have been keeping an eye on things. This is not their role, but thank goodness they have been, they notice things the managers don’t.”
 

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The provider and senior staff did not share an understanding of the risks, legal requirements and were not clear about their responsibilities. Cover for absent managers did not ensure consistent leadership, and therefore the reporting of incidents, risks, complaints and concerns was unreliable or inconsistent. This placed people at risk of avoidable harm and neglect. During the inspection, we observed both relatives and health professionals intervene in the care and support of people as they had identified risks to the person which the provider had failed to mitigate.

Shortfalls in audits and gaps in records had not been identified by the provider, during the inspection we met with the nominated individual who assured us they were committed to supporting necessary improvements and following the inspection findings. They had planned for an independent quality audit to be carried out.
 

People, their relatives and staff did not always feel they could speak up and that their voice would be heard.

Concerns raised to the service were not always followed up or documented. Records showed adverse events had reoccurred as actions was either not taken, or changes not sustained to ensure safety. This had placed people at risk of avoidable harm. Feedback received during the inspection was the management of the service did not always listen and address issues.

A staff member told us, “In my role I have picked up on and reported poor practice where I have been aware of it. It has mostly been acted upon although not always dealt with as swiftly as I would have hoped.”
 

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures incorporated all aspects of equality, diversity, fairness and protected characteristics. Staff had regular training to support inclusion and told us ways in which they seek support from colleagues to improve their resilience and develop their own skills.

A staff member told us, “I am proud that despite many changes and challenges that we have a core team of staff who really do care and do want the very best for our residents. I do genuinely believe that most staff want to work in a happy environment where care is the very best it can be. I am optimistic that the provider can support us in making Fairmile Grange Care Home a wonderful environment for people to live and work in.”
 

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were incomplete, inconsistent and not operating effectively. Systems had not been established and embedded to monitor the quality and safety of the care provided. The service had not identified the shortfalls found within this inspection and had not ensured legal and regulatory requirements were met in relation to statutory notifications, which is information providers must share with the CQC about events which occur in the service.

Evidence collected during the inspection consistently showed the provider did not have effective oversight of concerns and safety. Without a process in place the provider was not able to make improvements to the service in response to the changing needs of people who use the service. This placed people at risk of both abuse, harm and not having care needs identified or met.

Following the inspection, the provider told us they would be reviewing their system for auditing and arrange increased support to carry out independent spot checks. They said this would improve oversight moving forward.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

There was poor collaboration or cooperation with external stakeholders and other services. Information was not shared as required and there was little evidence of partnership working.

People and their relatives told us they were unhappy with some of the changes made, such as, further changes to the management team. Comments included, “You are just always starting over” and, “When staffing has changed, there has been no handover so there is no consistency for residents unable to tell you what they like and their hobbies.”
 

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had introduced new systems and processes to provide better oversight of the service. However, these had not been established to be able to identify the shortfalls found within this inspection. The newly appointed manager was confident when the systems and processes were embedded it would improve identifying risks and improvements would be identified. The manager was receptive to the feedback and demonstrated commitment to improvements, this was reflected in feedback from a health and social care professional following our inspection, who said, “The relatives of those I am supporting have had the chance to meet with the new manager and are hopeful the ongoing issues they have faced will finally be addressed.”