The Fairways

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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always 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 regulation in relation to premises and equipment.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Incidents had been recorded but not always thoroughly reviewed by management. Incident forms were closed on the provider system without all follow up actions being taken. For example, we found actions such as reporting incidents to other agencies such as CQC had not always been completed. It was not always recorded what the actions to prevent recurrence were. For example, incidents of distress did not have actions recorded to prevent further incidents of this type. The provider told us they had identified this shortfall and would be taking action to review incidents to identify any shortfalls.

There was a lessons learned section in staff meeting minutes. This had been used to share learning from events that had happened across the providers services. Staff told us there was a no blame culture at the service. They felt able to speak up when they had made an error without fear of blame. One member of staff told us, “It is a no blame culture. If a mistake happens, we don’t get told off. We learn from it and ensure it does not happen again.”

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.

When people were moving between services the service made sure they had the relevant information about the person’s needs. Staff also shared information with other services such as hospital staff and community nurses. During our assessment we observed a person was ready to return from hospital. The acting home manager instructed staff to complete an assessment and not to agree a discharge until any equipment was obtained. This helped make sure people had the equipment and support they needed in a timely way.

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

We found 3 incidents of safeguarding which had not been reported to the local authority. Whilst the provider took action to immediately address this shortfall, this meant the local authority had not been provided with an opportunity to investigate these incidents in a timely way to keep people safe. These concerns had also not been notified to CQC as required by law.

Whilst people raised concerns about a number of issues, they did not tell us they felt unsafe. One person told us they recognised some areas needed improving however they felt people were safe, they said, “The most important thing is that we are safe and well cared for.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff had applied for DoLS appropriately and where they were authorised, they were meeting any conditions.

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

Risks to people’s safety had not always been identified, this meant there was not always risk management plans for staff to understand and know how to support people safely. For example, for 1 person who was at risk of choking we found there was no guidance for managing this risk when the person moved around the service independently. We observed the person had access to drinks available in communal areas which was a risk to their safety as their fluids needed to be thickened. Leaders took action during our inspection to review the person’s risk plans. We also found another person was at risk of falls. Their room had hazards on the floor which had not been identified in their risk management plan.

Some people experienced distress and anxiety which at times had caused episodes of aggression with other people. Some people did not have behaviour support plans or there were not enough details for staff to know what to do if incidents of this type occurred. We shared this feedback with leaders who said they would review people’s plans without delay.

Actions to mitigate risks were not always effective as staff were not following guidance in risk management plans. For example, we observed 2 people with sensor mats in place to reduce the risk of falls. Sensor mats when triggered alerted staff to people moving around so they could respond and try to reduce falls. However, throughout our site visits we observed the sensor mats were in the middle of people’s rooms, not by their chair or bed wherever the person was. This meant if the person got up and moved around, the likelihood of them stepping on a sensor mat was reduced which put them at increased risk of harm.

The provider did not always 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.

The environment was dated and in need of repair in places. Health and safety checks had not been consistently completed. There were gaps in the records when the service had been without a maintenance person or when they were on leave. There had been no arrangements to make sure all checks were completed in the absence of a maintenance person.

When actions had been identified by external contractors, work to make the required improvement was not completed in a timely way. For example, emergency lights had been identified as faulty in November 2025. The provider obtained a quote for the remedial work in June 2026, 7 months after the fault was identified.

The acting home manager told us the service was going to have a refurbishment, and this had been agreed by the provider. Quotes had been obtained to replace carpets, furniture and to re-decorate. However, people, relatives and staff told us plans for refurbishment had been talked about for a long time, but nothing had happened. Feedback from people and relatives was that the environment needed updating.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Our first day of inspection was completed in the evening. We found there were not enough staff to safely meet people’s needs. After 8pm the service dropped to night staff levels which was 5 staff for 56 people. We observed many people with dementia were up and moving around the service. There were not enough staff to engage and support people in a timely way.

One member of night staff was administering medicines on 1 floor. This took about 2 ½ hours to complete. They told us once they finished the round they had to do medicines on the other floor. This was not an unusual occurrence for them to have to manage. This meant they would be administering people’s medicines after 10.30pm. The acting home manager said they were not aware medicines were taking this long and they would review night staff numbers.

Feedback from people and relatives was that there was not always enough staff. People said this was particularly noticeable at busy periods in the morning and evening. One person said, “Generally there are enough staff but a lot of them are agency. I need cream put all over me, this does not always happen as [staff] are in a rush.”

The acting home manager said they used a dependency tool, and they were staffed to recommended levels. Short notice sickness did happen, but where needed agency staff were used. The service tried to use the same agency staff for consistency of care. Following our site visit the acting home manager told us they would be reviewing staffing numbers.

Checks on agency staff had not been robust. Agencies had been asked to provide a staff profile for each member of staff. This included information about training and a check with the Disclosure and Barring Service (DBS). Some profiles we reviewed did not have information about a DBS check and this had not been followed up by the service. In addition, some profiles also recorded the agency staff training could be out of date. Again, this had not been followed up by the service.

Overall permanent staff had been recruited safely. However, 1 staff recruitment file did not have a detailed employment history, and this had not been explored. We shared this feedback with the provider. New staff were provided with an induction and training for their roles. This was refreshed when needed.

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

On our first day on site, we found the service was not clean. There was food debris and fluid spillages on counter tops, walls and floors. We observed dirt on windowsills, carpets and furniture. There were gaps in recording on cleaning schedules and staff said there were not enough of them to keep the service clean. Staff also said they did not have the equipment they needed to keep the service clean. Carpet shampooers had been out of action for some time and were not always fit for the work needed. The provider had ensured the delivery of an industrial floor cleaning machine. Three staff we spoke with told us, “We have been waiting for training to use this machine for some time now – we do not have anyone who knows how to use it.”

Communal toilets and bathroom had an odour emanating from the drains. This was especially noticeable at nighttime when they were used less. The acting home manager told us the provider had investigated this and were taking action.

People and relatives said there were times when the service was not clean. One relative told us, “I have observed repeated hygiene issues, including, infrequent cleaning of my [relative’s] room, debris remaining in the wet room for over a week, excrement around the toilet not being cleaned for several days and waste bins not being emptied unless requested.” However, some people said they thought their room was clean. One person said, “My bed is clean, the bathroom is clean, I have no complaints.”

The acting home manager took action following our feedback to clean the service. However, some areas of the environment had chipped paint which meant wood was exposed. Wood is porous and cannot be cleaned thoroughly.

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

Some people’s records did not contain sufficient person-centred information to fully support safe and effective medicines administration in line with best practice guidance. This included records related to covert administration and medicines -specific instructions. There were some gaps in ‘when required’ (PRN) protocols including completion of the protocol and completing other important details on the protocol such as route of medicine.

People requiring support with medicines, including those prescribed high-risk medicines including medicines for epilepsy, Parkinson's disease and self-administration arrangements had supporting documentation in place. Medication incidents were reported through the organisation's governance systems and investigated appropriately. Actions were usually taken where required. However, learning outcomes were not consistently documented across all incidents reviewed, increasing the risk of repeated incidents due to missed organisational learning.

Medicines were stored securely, administered by staff who were trained and who had been competency-assessed to handle medicines.