Background to this inspection
Updated
22 February 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 was carried out by one inspector.
Service and service type
Fairhaven Lodge is a ‘care home’ without nursing care. 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. 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 a registered manager in post.
Notice of inspection
This inspection was unannounced.
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
During the inspection, we spoke with 3 people who used the service. We also spoke with one person’s relative and received feedback from 5 relatives via email. We spoke with 6 staff, including the registered manager and a visiting professional. Following the inspection visit, we gained feedback from 4 external professionals about their experience of working with service.
We looked around each area of the home to make sure It was safe, homely and suitable. We spent time observing the care and support people received. This helped us to understand the experience of people who could not or chose not to speak with us.
We reviewed five people’s care documentation and multiple medicines administration records, along with associated medicines documentation. We observed medicines administration and checked how medicines were stored.
We reviewed a range of records related to the management of the service, including safety certificates, staff training data and quality assurance systems.
Updated
22 February 2023
About the service
Fairhaven Lodge is a residential care home providing personal care for up to 25 people, aged 65 and over who were living with dementia. At the time of our inspection, 23 people were living at the home.
People’s experience of using this service and what we found
The provider had made improvements to try to ensure people’s care was delivered safely. Staff were recruited safely and there were enough staff on duty to meet people’s needs. One person’s relative told us, “More full-time staff would be good, like many care homes in this climate of staff shortages. This does not stop the amazing professional care my mum receives.”
The registered manager had fostered a culture that was open and inclusive, and put people at the centre of the care they received. One person’s relative told us, “[Registered manager] is an asset. She cares for everyone and is hands-on.” Another said, “I have found Fairhaven and its staff to be excellent in looking after Mum, making her final years as comfortable as possible.” They went on to say, “I cannot think of anything to make me feel Fairhaven hasn’t been an excellent choice of care home for Mum, in fact I can’t recommend it highly enough.”
Medicines were managed safely, and staff kept the home clean and tidy. Staff managed risks well and had plans to follow in case of emergencies. The service had systems to protect people from the risk of abuse and improper treatment.
Governance at the service had improved. Staff understood their roles and responsibilities and worked well with external agencies to meet people’s needs. The provider monitored the quality of the service using a range of systems.
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 23 March 2021) and there were breached of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
At our last inspection we made recommendations to the provider around calculating staffing levels, medicines competency checks and learning from adverse events. At this inspection we found the provider had acted on our recommendations and made improvements.
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 carried out an unannounced inspection of this service on 11 and 17 December 2020. 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, Fit and proper persons employed and Good governance.
We carried out this focused inspection to check they had followed their action plan and to confirm 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 good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Fairhaven Lodge on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.