Archived: The Fairways

Updated 25 July 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 12 and 13 June 2017 and the first day was unannounced. The inspection was conducted by an adult social care inspector 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. A second adult social care inspector accompanied the inspection team on the first day as part of their induction.

Prior to the inspection we reviewed information we held about the service. This included notifications the home is required to send us about safeguarding, serious injuries and other significant events that occur whilst delivering a service. We reviewed any feedback we had received about the service since our last inspection that had been given to us via email, phone or a ‘share your experience’ web-form. We had received feedback from one person who provided positive feedback on the service.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We reviewed this along with the last inspection report and the provider’s action plan they sent to us following the inspection. We sought and received feedback from the local authority quality assurance team, Trafford Healthwatch, the infection control team and two professionals with recent involvement in the service. We used this feedback to help plan our inspection.

During the inspection we spoke with seven people who were living at The Fairways, and seven friends/relatives who were visiting at the time of the inspection. We spoke with eight staff members including three care staff, the registered manager, the deputy manager, an activity co-ordinator, the nominated individual and the compliance officer. We also spoke with a visiting district nurse and food safety officer.

We carried out observations of the care provided, and 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.

We reviewed records in relation to the care people were receiving. This included daily records of care, six care plans and four medication administration records (MARs). We reviewed other records relating to the running of a care home, including records of training, supervision, servicing and maintenance, audits and quality checks and four staff personnel files.

Updated 25 July 2017

This inspection took place on 12 and 13 June 2017 and was unannounced.

We last inspected The Fairways on 08 and 09 September 2016 when we rated the home inadequate overall and placed the home into special measures. We identified breaches of multiple regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following our last inspection we issued two warning notices in relation to breaches of regulations relating to the provision of safe care and treatment and good governance. This meant we sent a formal notice to the provider and registered manager that they must become compliant with the regulations by 22 October 2016 in relation to safe care and treatment, and 15 November 2016 in relation to good governance. The provider sent us an action plan to tell us the improvements they would make in order to become compliant with the regulations. At this inspection we found the provider had made significant improvements and they were meeting the requirements of the regulations.

The Fairways is a large detached house on a main road close to the centre of Flixton. There is a small car park at the front of the property. The home is registered to provide accommodation and personal care for up to 20 people. At the time of our inspection there were 20 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had improved quality assurance and audit processes since our last inspection. We saw a wide range of audits were undertaken to help the provider monitor the quality and safety of the service. The findings of the daily and weekly audits were analysed for themes, and actions identified as to how the service could make improvements.

The provider had sought the opinions of people using the service and their relatives as to the strengths and areas for improvement the service had. The findings of questionnaires sent out were analysed and used to set targets for improvement.

People told us they felt safe living at the home. Staff were aware of how to identify and report potential safeguarding concerns.

Staff felt there were ‘pressure points’ in the day when staffing levels could be improved. However, staff did not feel this had an impact on people’s care. The provider had a process for considering how many staff were required, and during our inspection we saw staff were available to provide support to people whenever needed.

Staff had assessed risks to people’s health, safety and wellbeing. This included consideration of risks including falls, pressure sores, malnutrition and social isolation. There were plans in place for staff to follow to reduce risks, and we saw any equipment such as mobility aids or pressure sensors were in place as directed in people’s care plans.

Newly employed staff had been recruited following robust procedures to ensure they were suitable for the job role. The provider had recognised that historic recruitment procedures had not been robust, resulting in missing references and gaps in employment histories. The provider had carried out an audit of any required information that was missing and was taking action to satisfy themselves that staff remained suitable for their job roles.

A recent infection control audit had identified shortfalls in the prevention and control of the spread of infections. Issues included the lack of a separate laundry facility or bed pan washer. The provider had an action plan in place to address these concerns, and they showed us plans for works to provide a separate laundry and to purchase a bed pan washer. However, the works had not started at the time of the inspection, which the provider told us was due to them awaiting a re-inspection by CQC.

The provider had changed the way food was provided. Meals were prepared by a third party contractor and delivered to the home. People gave us positive feedback about the meals, and we saw people’s dietary requirements were being met.

Staff had received training in a variety of topics relevant to their job roles. The provider had identified some gaps in training provision and was in the process of booking additional training. We have recommended the provider reviews the scope of the training they have determined to be mandatory.

Staff had received supervision with a manager and felt supported, although formal supervision was infrequent. We have recommended the provider reviews best practice guidance in relation to supervision.

We found the home was well organised and there was a calm environment. Staff were attentive, and interacted positively and respectfully with people. The Fairways is located in an older building, and we found there was limited communal space or adaptations to make the environment more ‘dementia friendly’. However, relatives commented on the ‘homely’ feel of The Fairways.

We received consistently positive feedback from relatives and people living at the home about the staff and the service in general. Staff knew the people they supported well, and relatives were confident that staff were able to meet their needs. The service made appropriate referrals to other health professionals when further advice was required in relation to any health concerns.

Care plans were personalised and contained information on people’s preferences, likes, dislikes and personal history, although the level of detail recorded was variable. Relatives told us they were confident staff understood their family member’s preferences, and they told us they had been involved in developing care plans.

The home employed activities co-ordinators and a range of activities in and out of the home were provided. Staff had considered the need for activities and interaction with people who may be at risk of social isolation.

The home used an electronic care management system to make records of care provided and for care plans. Staff told us the electronic system worked well and they were able to find the information they needed when required.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.