CQC report explained · a nursing home
What the CQC found at Fairburn Mews
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2022
Fairburn Mews is rated Requires Improvement; inspectors found risks in care and weak checks, although staff knew people well and were caring.
Inspectors visited on 17 May and 08 June 2022. They spoke with four people, nine relatives and 19 staff. They observed care and checked care plans, risk assessments, medicines records, recruitment files and quality checks.
The home was not always safe. Risk controls were not always followed, safeguarding concerns were not always dealt with correctly, and medicines records and audits were not always reliable. Some people were also at risk of having their liberty restricted without the right assessment or paperwork.
The home was not always well-led. Care records were not consistently personal or up to date, communication was not always effective, and quality checks did not always identify problems. However, staff knew people well, some relatives gave positive feedback, and the new management team was described as open and supportive.
The overall rating fell from Good at the previous inspection in 2017 to Requires Improvement. The report says the provider had to send an action plan, and CQC would continue to monitor progress.
Staff knew people well
Staff understood people's care and support needs. Inspectors saw caring and dignified support.
“Staff knew people well and understood their care and support needs.” from the report
Positive staff support
Staff said the new management team was approachable and supportive. Staff meetings gave them opportunities to raise concerns.
“Staff told us the management team were approachable, open, fair and supportive.” from the report
Sufficient staffing
Inspectors found staffing levels were enough to meet people's needs, including support at times when one or two staff were required.
“Staffing levels were sufficient to meet people's needs.” from the report
Family contact
The home supported family meetings and visits, including arrangements for a person whose family lived far away.
“The home was facilitating 'meet in the middle' visits for this person to encourage regular contact.” from the report
Risk controls were not reliable
seriousRisk management measures were not always followed. This included safety arrangements for people who smoked and support for behaviours that may challenge.
“People were not safe from the risk of harm as risk management measures in place were not always effective or followed by staff.” from the report
Safeguarding responses
seriousStaff knew how to recognise and report abuse, but procedures were not always followed. Some incidents were not properly reduced, investigated or reported.
“We found staff did not follow procedures resulting in people being at risk of abuse.” from the report
Medicines management
seriousMedicines were not always given or recorded safely. Cream records lacked clear application details, some doses were missed for day trips, and audits did not always match people's needs.
“People's medicines were not always safely managed.” from the report
Care records and liberty safeguards
needs fixingSome care plans were not personal or up to date. Liberty restrictions and mental capacity decisions were not always assessed, documented or referred to in time.
“We found the provider was not working within the principles of the MCA.” from the report
Weak quality checks
needs fixingAudits and other governance systems did not reliably identify problems or show that lessons had been learned. The management team was not always aware of people's needs and risks.
“Procedures in place to monitor quality and performance were not always effective.” from the report
Infection control assurance
needs fixingInspectors were not assured that personal protective equipment was being used effectively and safely. The provider took action to review infection control measures and remind staff of current guidance.
“We were not assured that the provider was using PPE effectively and safely.” from the report
- 01What changes have you made to risk assessments and staff practice for people who smoke?
- 02How do you now record, investigate and report safeguarding incidents?
- 03How do you check that medicines, including creams, insulin and doses missed for outings, are managed correctly?
- 04How are mental capacity decisions and any restrictions on liberty assessed, authorised and recorded?
- 05What evidence can you show that care plans and quality audits have been reviewed and improved?
This was a focused inspection of Safe and Well-led; the other key question ratings were not inspected in this visit and the overall rating used previous ratings for those areas. This explanation was written from the published report of 10 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2021
Fairburn Mews was inspected but not rated; inspectors found strong infection prevention and control arrangements.
This was a targeted, announced inspection on 31 March 2021. It looked at how well the home was prepared to prevent and control COVID-19 infections.
Inspectors found good arrangements for visitors, including pre-booking, temperature checks, questionnaires, lateral flow testing and cleaning between visits. They also found suitable supplies of protective equipment and regular testing for staff, visitors and residents.
The home was clean and maintained. Staff used protective equipment correctly, and the layout, cleaning routines and staff training supported infection control. People were also supported to keep in contact with others through options such as video calls.
The home was inspected but not rated. This means the report does not provide a current overall rating or full ratings for the five areas of care.
Visitor infection controls
The home had a clear process for visits, including pre-booking, testing, temperature checks and cleaning between visits.
“There was a clear pre-booking system and deep cleaning was undertaken between each visit.” from the report
Protective equipment and testing
Inspectors found protective equipment was available and used properly. Testing was in place for visitors, staff and residents.
“We observed staff wore a full range of PPE appropriately and consistently.” from the report
Clean and safe environment
The home was described as clean and maintained, with signs about distancing and regular deep cleaning.
“We observed the home to be clean, maintained and with a programme of improvements.” from the report
Keeping people connected
Staff supported people's social and emotional wellbeing, including through video calls and other ways of staying in contact.
“Alternative forms of maintaining social contact were in place including, video calls.” from the report
Inspectors raised no specific concerns in this report.
- 01What is the home's current overall CQC rating, given that this inspection was not rated?
- 02How have infection prevention and control arrangements changed since the inspection on 31 March 2021?
- 03What arrangements are currently in place for visitors, including testing, protective equipment and cleaning?
- 04How does the home now support residents to maintain social contact with family and friends?
- 05Can you explain the home's current admission and discharge process?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide a full rating of the home or assess the other four key questions. This explanation was written from the published report of 24 April 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Fairburn Mews
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- October 2017Goodstayed GoodSafe: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 22 February 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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92 live-in carers within about an hour of Wakefield
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Most charge £980 to £1,260 a week. 79 can care for a couple. 12 years' experience on average.
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