Fairland House

We last carried out an assessment to the service between the 09 and 24 January 2024 looking at all five key questions, Safe, Effective, Caring, Responsive, and Well led. The overall outcome of the previous assessment was that it required improvement with an inadequate rating in well led and three breaches of regulation: Regulation 12: Safe care and treatment, regulation 17, Good Governance and regulation 18 Safe staffing which were summarised in a warning notice served in February 2024.

We carried out a further assessment of Fairland House 06 March 2025, a restriction on admissions was still in place by the local authority due to concerns about the service’s performance over time. At the time of our latest assessment there was an acting manager and deputy manager in post who had made improvements including environmental improvements and higher standards of cleanliness. People received their medicines in a timely way and improvements were noted in social activities and staffing levels. Previous breaches of regulation 12 and 18 had been met.

Governance and oversight of this service had been a concern with a breach identified at the last assessment. Whilst improvements had been made, these were not firmly embedded and did not assure us that people had received a consistently good service over time. During our assessment in January 2024, we reported that the providers records did not provide a clear audit trail, and we found poor governance and oversight specifically in relation to accidents and incidents not being recorded or dealt with appropriately. A provider audit completed in December 2024 highlighted concerns about incidents, accidents and safeguarding concerns stating these were not being reported, collated or escalated appropriately. This is 11 months after we flagged these concerns and did not demonstrate timely, or robust actions had been taken. Whilst on site we identified a significant incident which had not been reported to safeguarding or CQC and the lessons learnt document was not sufficiently robust or implemented in a timely way.

Monthly provider audits identified care plans were not routinely updated or reviewed and new admissions to the service had poor documentation in place. In February 2025 the provider identified only five care plans were up to date. During our assessment we found care plans were being updated but had not been regularly reviewed and there were no clear systems to do so. We failed to see how the home’s dependency tool could be accurate without an up-to-date review of people’s needs. We also failed to see how staff could be expected to provide adequate care without an up-to-date plan. Relatives told us they were kept informed of issues affecting their family members/friends, but none spoken with had been involved in care plan reviews.

There was a high use of agency staff although recruitment of new staff was improving. Relatives reported that there were always familiar staff on duty which they found reassuring. Agency profiles showed some agency lacked experience and had completed very basic eLearning. Regular staff had expressed concern about leaving agency staff unsupervised. Senior staff over time had not been given the support they required to competently carry out their roles due to the previous lack of management oversight and support. This was however improving. The manager was not yet registered with CQC and had only been in the service three months at the time of our assessment.

Risks associated with high numbers of falls had been analysed as occurring more at certain times of the day. Rotas showed a drop in ancillary staff, no activity staff and no senior management on shift at the weekend. The deployment of staff was an important factor in determining how effectively people's needs were met. Minutes from staff meetings demonstrated that staff struggled to meet the needs of people at busier times of the day.

Improvements across the service had only recently taken place and further improvements were required to ensure record keeping and analysis was more robust and admissions to the home were properly documented and in line with staff skills and competency levels. Staff supervision and enhanced training needed to be improved, but we acknowledged the manager had brought some stability to the service.