Fairburn Mews

Updated 10 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was conducted by two inspectors and one bank inspectors and an Expert by Experience; An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Fairburn Mews is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Fairburn Mews is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced on the first site visit and announced on the second site visit.

What we did before the inspection

We completed a review of all the information we held about the service including information the service is required by law to tell us about. We requested feedback from stakeholders, including; the local safeguarding team, Infection, prevention and control team and commissioning team. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used information gathered as part of monitoring activity that took place on 08/03/2022 to help plan the inspection and inform our judgements.

We used all this information to plan our inspection.

During the inspection

We spoke with four people who used the service and nine relatives about their experience of the care provided. We observed care in the communal areas to help us understand the experience of people. We gathered information from 19 members of staff including the management team, nurses, care staff and a chef.

We reviewed a range of records including; three people’s care plans, risk assessments and associated information, other care records to follow up on specific concerns and multiple medicines records. We looked at two staff files in relation to recruitment. We reviewed a variety of records relating to the management of the service, including policies, procedures and quality assurance records.

After the inspection

Following the inspection, we requested and reviewed further information from the provider relating to peoples and the service’s risk management procedures, medicines management, infection prevention and control, training and quality assurance processes. We shared information with the local safeguarding team and fire prevention team about concerns that we found at the service.

Updated 10 August 2022

About the service

Fairburn Mews is a nursing home providing accommodation for persons who require nursing or personal care for up to 20 people. The service provides support to people who have physical and mental health needs. At the time of our inspection, there were 19 people using the service.

The home is set out across two separate floors, each of which has adapted facilities.

People’s experience of using this service and what we found

Out of the four people and nine relatives we spoke with, 11 shared positive feedback. However, our findings indicated people did not always receive safe care and the service was not always well-led.

People’s risk management was not always appropriately assessed and mitigated by staff and behaviours that may challenge was not always appropriately managed.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests.

The requirements of the Mental Capacity Act were not always being followed. We found some people who lacked capacity in relation to some areas of their care, did not appropriately have their liberty restricted as part of their care arrangements and this was not always properly assessed and documented in a timely manner.

Care plans were not always person-centred or reflective of the person’s voice. The provider was receptive of feedback and told us they will be completing a review of all people’s care records.

The provider was not always using their quality processes effectively to monitor the service and our inspection-initiated action from the provider to improve safety and quality monitoring for people.

Staff knew people well and understood their care and support needs. One relative said, “They know [person] so well they know [person] better than me”. We saw staff supporting people in a caring and dignified way, but records did not always reflect this practice.

The service had a new management team and staff feedback was positive and indicated the management team were open and supportive. People knew who the registered manager was, and one relative said, “The atmosphere is very positive, there is a family dynamic.” The registered manager and provider were receptive of feedback and acted promptly for some areas of concern raised during the inspection process.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 10 October 2017).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services. To understand the experience of social care providers and people who use social care services, we asked a range of questions in relation to accessing urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Fairburn Mews on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk management and lack of good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.