Fairfield Nursing Home

At the last assessment the provider was previously in breach of the legal regulations in relation to the need for consent, fit and proper persons, medicines management, risk management and governance.

During this assessment, we identified breaches of the legal regulations in relation to person centred care, safe care and treatment, and good governance. This service has been placed in special measures. The purpose of special measures is to ensure services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.

We shared our concerns with leaders during the assessment. They took immediate action to begin addressing cleanliness issues and implementing changes to improve the safety of the environment and care planning and risk assessment documentation.

Although structured and regular audits were in place, we identified a gap between leadership intentions and operational delivery in key areas. Governance systems were not effective in driving improvements, particularly in infection control, cleanliness, medication safety, environmental risks, and record keeping. Lessons from the previous assessment and internal reviews had not been embedded into practice. We observed unsafe evacuation plans, unresolved environmental hazards, poor hygiene despite cleaning records being signed off, and reliance on generic care plan templates. Care records contained repeated contradictions, omissions and dismissive language about people, demonstrating the provider had not established a culture of continuous improvement or acted effectively on previous regulatory concerns.

We found safety issues, including unlocked hazardous storage areas, faulty locks, and environmental hazards such as trip risks, broken fixtures, and uncontrolled access to outdoor areas and maintenance tools. Infection prevention control was poor, with improper Personal Protection Equipment (PPE) use and disposal, and we observed dirty equipment throughout the home.

Personalisation was not consistently promoted in the environment. People’s bedroom doors were not labelled with their names or identifiers, making it difficult for them to recognise their own rooms. Our review of care plans highlighted recurring problems in communication, risk management, person-centred planning and emergency preparedness. Care plans did not always include detailed, personalised information about the support people needed with medicines or provide accurate, up-to-date information on the medicines prescribed.

Some staff members we spoke with raised concerns about time pressures that limited their ability to review care plans and complete documentation. They told us they felt some risk assessments lacked clarity regarding the level of risk and appropriate mitigation strategies.

The provider had established processes for escalating safeguarding concerns promptly and sharing lessons learned with the wider team. Professional partners confirmed these were discussed during contract meetings.

Staff recruitment followed appropriate procedures, and agency staff were inducted and supervised effectively. Staff had the right skills and experience to meet people's needs.

We observed staff consistently interacted with people in a kind, respectful, and patient way. They offered encouragement, reassurance, and used humour appropriately, which helped create a calm and supportive environment. One staff member told us, “I love my job, and I love the resident’s.”