Fairhaven 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the 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 governance at the service.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The management team was committed to providing a caring, person-centred service which promoted people’s rights and there was a culture of openness, learning and continuous improvement. The management team provided stable and effective leadership that had fostered an inclusive culture. Discussions with staff and our observations whilst at the home reflected this ethos.

All people and relatives we spoke with were positive about the atmosphere and culture at the home. We observed staff were respectful, caring and committed to providing good quality care and treatment to people living at Fairhaven Care Home.

The providers statement of purpose set out a clear vision to provide person-centred care, prioritising dignity, respect, and creating a safe and homely environment.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The registered manager and deputy manager of Fairhaven Care Home demonstrated they understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce. The management team had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. However, we identified some staff who were delegated specific roles and responsibilities did not consistently demonstrate sufficient capability to identify and address risks in a timely way. This included medicines management, environmental safety and infection prevention and control.

People, their relatives and professionals spoke positively of the leadership of the service and confirmed they were visible and approachable at all times. Comments included, “I do think it’s well managed. It’s like a home from home. You can tell the staff know the patients. It’s a nice atmosphere”, “I think they are well organised”, “I have complete confidence in the staff” and “I would say ten out of ten, just their communication, time for residents and their families.”

Discussions with staff at all levels of showed they knew people, relatives and staff individually. External professionals were positive about the management team at the home.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People and relatives, as well as external professionals felt able to raise anything with the management team, they told us they would be listened to and actions would be taken when required.

Staff were positive about working at Fairhaven Care Home and described the management team as available and approachable. Staff told us that they felt able to raise concerns at any time and felt they would be listened to.

There was no evidence of closed cultures. All staff were complimentary about each other and the way colleagues treated them.

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

There was an inclusive and fair culture with equality and equity for staff. Staff told us they were happy at the service, felt supported and had the right support in place to enable them to do their jobs well. Staff told us, they felt valued and respected by the management team and each other.

The registered manager told us they fully supported flexible working and staff confirmed this.

Staff received equality and diversity training, and the provider had policies in place relating to equality and diversity.

The provider 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.

Audits and governance procedures were not always effective and had not identified the issues we found during the inspection. For example, the checks and audits completed in relation to fire safety were not robust. This included but was not limited to, the door safety check record which did not include all doors within the service and failed to identify any of the issues we found in relation to door safety and that fire alarm/detectors were not in all areas that required them. Additionally, audits and processes failed to identify the issues we found in relation to environmental safety, infection prevention and control and medicine management. These failings demonstrated there was ineffective governance systems in place in some areas. As a result, people could be exposed to the risk of avoidable harm. These concerns were discussed with the provider during the assessment process who confirmed immediate action would be taken to address these issues.

The views of people using the service, their relatives and staff were sought using both formal and informal processes including, face to face meetings, questionnaires and general conversations. Feedback was analysed and acted on.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Management and staff worked towards the shared aim of achieving positive outcomes for people. The registered manager encouraged the team to openly discuss, feedback and exchange ideas for continuous improvement and innovation.

Feedback from external professionals was exceptionally positive about how the service worked collaboratively with them. Professionals told us the management team and staff were proactive in seeking advice and responsive to feedback. One professional said, “As a professional visiting the home I have been able to speak with [name of registered manager] with regards to concerns or issues that I may have whilst visiting, she has met these with open and honest discussions and has been quick to respond should I have questions outside of my visit.” Another professional told us, “Fairhaven are very proactive when it comes to requesting referrals, visits from the GP or ANP or updating any changes. I feel like any advice or instructions are followed by the care team and these seem to be communicated throughout the team. I do feel that I could discuss any concerns with [Name of registered and deputy manager] and that they would address any changes that need to be made.”

People’s relatives also described how they were encouraged and supported to work in partnership with the service to help ensure seamless and person-centred care could be provided to people. A relative said, “They made time to get to know and understand [person], they liaised well with social services. They cared about [person].” Another relative said, “They talk to me or call me. They are very good at ringing me; they are very amenable.”

The provider 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.

Leaders had an approach to continuous learning and improvement related to some aspects of care, including information on the number and type of falls, specific issues or concerns that had been raised and types of incidents and accidents that had occurred was easy to review which helped to establish trends and patterns. However, some aspects of safety in the service had not been fully considered in improvement plans to ensure they were addressed, such as the safety of the environment, safe management of medicines and suitability and skills of staff delegated to specific tasks.

At the time of our assessment there was an ongoing action plan in place which detailed any actions required that had been identified through the services governance systems or highlighted through stakeholders. The management team were open to feedback provided during and following the site visits and were committed to making the necessary improvements.