CQC report explained · a residential care home
What the CQC found at Fairhaven Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe staffing and recruitment, safe medicines management, improved infection control, and good systems for managing risks and emergencies. They noted that one lounge was sometimes left unattended.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Inspectors found clear responsibilities, improved governance, accurate records, a positive culture, and good engagement with people, relatives, staff and external professionals.
What inspectors found, February 2023
Rated Good after improvements; inspectors found safe, well-managed care, with some remaining work on staff deployment and care records.
This was an unannounced focused inspection on 24 January 2023. One inspector spoke with people, relatives, staff and professionals. They observed care, checked the home, reviewed care and medicines records, and examined staffing, safety and quality checks.
The home was rated Good for Safe and Well-led. Inspectors found enough staff overall, safe recruitment, safe medicines management, improved infection control, and better systems for managing risks and learning from incidents. The home was clean and emergency plans were in place.
Inspectors found an open culture where people, relatives and staff could give feedback. Records had improved and were accurate and up to date. There were times when one lounge was left without staff, and some care plans did not include everything staff knew about people's needs.
The previous rating was Requires Improvement, published in March 2021, with breaches of regulations. Inspectors said the provider had acted on its action plan and was no longer in breach. The overall rating became Good, but this visit only directly assessed Safe and Well-led.
Improved safety
The provider had acted on earlier concerns. Fire safety, infection control, risk management and emergency planning had improved.
“At this inspection, we found the provider had made improvements and was no longer in breach of regulation 12.” from the report
Safe medicines
Staff were trained and checked as competent to give medicines. Written instructions were available for medicines given when needed or hidden in food or drink.
“Medicines were managed safely and properly.” from the report
Safe staffing and recruitment
The provider used people's needs to help decide staffing levels. Recruitment checks were completed and inspectors found enough staff overall.
“There were enough staff on duty.” from the report
Open management
The manager and staff were described as experienced and approachable. People, relatives and staff were able to give feedback and influence aspects of the service.
“The registered manager had created a culture that was open, inclusive and put people at the centre of the care and support they received.” from the report
Better records and oversight
Governance systems had improved. Inspectors found accurate, up-to-date records and regular checks to monitor and improve the service.
“Accurate and up to date records were maintained.” from the report
One lounge sometimes unattended
needs fixingAlthough staffing levels were generally enough, inspectors saw times when one lounge had no staff present. The manager said this had been identified and was being addressed.
“However, there were times during our inspection when one lounge was left unattended by staff.” from the report
Care plans did not contain all staff knowledge
minorIn some cases, staff knew more about people's needs than was recorded in their care plans. The manager said this was an area for further improvement.
“In some cases, staff knew more about people than was included in care plans.” from the report
- 01How do you make sure every lounge is supervised at all times, especially when staff are leading a shift?
- 02How are staff's day-to-day knowledge about a person's needs added to and checked in their care plan?
- 03What were the ratings for Effective, Caring and Responsive at the previous inspection?
- 04How do you check that improvements made after the previous Requires Improvement rating continue to work?
- 05How will you share lessons from accidents and incidents with the staff team?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 22 February 2023 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, March 2021
Fairhaven Lodge was rated Requires Improvement; inspectors found infection, fire safety, recruitment and management record problems.
This was an unannounced, focused inspection after concerns about infection control. One inspector spoke with the management team and staff, looked around the home and checked records, policies, certificates and quality checks.
The home was experiencing a COVID-19 outbreak. Inspectors found several infection control problems, an unsuitable fire risk assessment and weaknesses in staff recruitment checks. They also found that staffing levels were not worked out systematically and that some care risk records were not up to date.
The home’s quality checks had stopped after the previous registered manager left. Important records were incomplete or inaccurate. The management team accepted the feedback and acted on some issues after the inspection, including replacing bins, cleaning equipment, increasing night staffing and arranging a new fire risk assessment.
The overall rating fell from Good at the previous inspection, published in June 2019, to Requires Improvement. This means the service was not always safe or well-led, with limited assurance about safety and an increased risk that people could be harmed.
Medicines administration
People received their medicines on time. Only trained staff administered them, and there were written instructions for medicines prescribed when required.
“Medicines were managed safely and properly. People received their medicines when they should.” from the report
Protection from abuse
Inspectors found systems for recording, reporting and analysing allegations of abuse. Staff knew how to recognise abuse and what action to take.
“People were protected from the risk of abuse. The provider had systems to record, report and analyse any allegations of abuse.” from the report
Staff commitment during the pandemic
During the first wave of the pandemic, the staff team lived at the home for 11 weeks to help protect residents.
“During the first wave of the pandemic, the staff team moved into the home for 11 weeks to keep people safe” from the report
Open management response
The management team accepted the inspectors’ feedback, provided requested information and acted promptly on some concerns.
“The management team were receptive to our feedback and were keen to make improvements to the service, responding promptly to our concerns.” from the report
Infection control
seriousInspectors found dust, bins that had to be touched and equipment that had not been thoroughly cleaned. The manager had not completed an infection control audit at the time.
“The provider had not ensured people, staff and others were protected against the risk of infection.” from the report
Fire safety
seriousThe fire risk assessment was not suitable or sufficient. A later assessment identified several areas of moderate risk that needed action.
“We found the provider's fire risk assessment was not suitable and sufficient.” from the report
Staff recruitment checks
seriousTwo staff had started work before full DBS certificates were received. Required explanations and risk assessments were not recorded.
“Both staff had begun working at the home before a full Disclosure and Barring Service (DBS) certificate had been received.” from the report
Quality monitoring
seriousQuality assurance activity had stopped after the previous registered manager left. The checks had not identified the problems found by inspectors.
“We found all quality assurance activities had stopped when the registered manager left their post in September 2020.” from the report
Staffing cover
needs fixingThe provider could not show how staffing levels were calculated. The fire service raised concerns about whether two night staff would be enough for an emergency evacuation.
“The provider did not take a systematic approach to calculating staffing levels.” from the report
- 01What actions have you completed following the infection control concerns, and how often are infection control audits now carried out?
- 02What is the current fire risk assessment, and how would residents be evacuated in an emergency?
- 03How do you calculate staffing levels, including night cover, and how do you make sure communal areas are supervised?
- 04Have all staff recruitment records now been checked for DBS certificates, employment gaps and any required risk assessments?
- 05How are you now checking the quality of care records and learning from accidents and incidents?
This was a focused inspection of Safe and Well-led after concerns about infection control; the other three key questions were not inspected and their previous ratings carried over. This explanation was written from the published report of 24 March 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 Fairhaven Lodge
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2019Goodstayed GoodSafe: GoodWell-led: Good
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 14 April 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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85 live-in carers within about an hour of Lancashire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 78 can care for a couple. 11 years' experience on average.
“She understands the needs of an elderly person in the early stages of dementia and has treated my mother with great kindness and skill.”
“Thanks to Tracy, Dad was always immaculately dressed and clean, his meals were all home cooked and nutritionally well balanced and his home was always kept really clean and tidy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.