Fairways

Updated 5 September 2023

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

The inspection team consisted of 2 inspectors and 1 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

Fairways 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. Fairways is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been in post for 8 months and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 1 June 2023 and ended on 21 July 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the Local Authority and professionals who work with the service. 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 all this information to plan our inspection.

During the inspection

We spent 2 days on site observing the provision of care. We spoke with 3 people who used the service and 8 family members. We spoke with 7 members of staff including the manager, senior staff, care workers, and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records. This included 3 people’s care plans, 5 staff files, and a variety of records relating to the management of the service including health and safety and quality assurance. We requested documentary evidence to review remotely following the inspection site visit.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 5 September 2023

About the service

Fairways is a residential care home providing personal care for up to 24 people. The service provides support to older people and people with dementia. At the time of our inspection there were 19 people using the service. The service is in 1 large, adapted home over 3 floors with a lift, lounge areas, an outdoor seating area, and 2 dining rooms.

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

People did not have adequate, complete, and up-to-date person-centred care plans and risk assessments. This meant there was a risk people’s individuality, preferences, and risks might not be understood by all staff and people may come to harm.

Fire safety measures, security checks, and emergency planning were not adequate. Management and oversight of fire safety and emergency planning was not consistent and up to date. Security checks did not include all areas. This meant should there have been an emergency, or an area left insecure, people would have been at risk of harm.

Recruitment practices adopted by the home were not robust. The provider did not have a clear system with documented evidence of all requirements and checks. The recruitment policy and procedures did not support safe recruitment. There were no regular checks on recruitment files. This meant it was not always possible to evidence all staff were safe to deliver care to people.

Systems in place were not effective enough to support the safe management and administration of medicines. The provider was changing from paper-based systems to electronic systems, causing duplication of entries and two systems were running at the same time. Time-specific medications were not managed well. Medication audits were not effective. This placed people at risk of harm from unsafe practices in relation to the management of medicines. The systems around the management of controlled drugs were safe.

Processes and systems in place to oversee, assess, and monitor the safety and quality of service provided were not effective. The provider had started a new quality assurance system, this was not embedded. The provider’s policies were not current. This meant appropriate actions may not be taken to ensure the service consistently provided safe care and treatment.

People and their relatives felt the service was safe. Relatives told us there were enough staff around who were kind and attentive to people’s needs. There was training for staff in keeping people safe and the manager was checking to ensure staff understood the training.

The management of infection prevention and control was good. People in the home, staff and visitors were kept safe from infection following current guidance.

The manager was learning lessons when things went wrong. There were checks on falls where the manager was looking for trends and any themes to make improvements. The manager had an improvement plan of things she was acting on.

The provider had clear vision and values regarding the support they provided. There were regular meetings with the manager and provider. Staff told us they were supported by the manager. People who used the service and their relatives found the manager approachable, and they acted on any concerns quickly. The service was working well in partnership with other healthcare professionals and the local authority.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 3 March 2022) and there were breaches of regulation. At this inspection we found the provider remained in breach of regulations. The service is now rated inadequate.

Why we inspected

We carried out an unannounced focused inspection of this service on 1 and 6 June 2023. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance. We undertook this inspection to check they had followed their action plan and to confirm if they now met legal requirements.

This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. 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 requires improvement to inadequate. This is based on the findings at this inspection.

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 the service can respond to COVID-19 and other infection outbreaks effectively.

We found evidence during this inspection people were at risk of harm regarding our concerns. We have found evidence the provider needs to make improvements. Please see the relevant key questions sections of this full report for the action we have asked the provider to take.

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

Enforcement

We have identified continued breaches in relation to safe care and treatment, good governance, and fit and proper persons employed. Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall, we will act in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.