CQC report explained · a nursing home
What the CQC found at Fallowfield
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found kind and responsive care, but medicines, risk records and quality checks were not always safe or effective.
Inspectors visited unannounced on 31 October and 2 November 2022. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The main concerns were medicines management and care records about risks. Some medicines did not have clear instructions, and records did not always show when liquid medicines were opened. Some care plans and turning charts were not updated or completed as required, which put people at risk.
The home was rated Good for Effective, Caring and Responsive. People were supported by skilled staff, treated kindly, offered activities and helped to make choices. The home was rated Requires Improvement for Safe and Well-led.
The overall rating fell from Good at the previous inspection, published on 28 January 2021. The provider must send CQC an action plan, and CQC will continue to monitor the home.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff treating people with dignity, respecting privacy and supporting independence.
“Throughout our inspection we observed positive caring interactions between people and staff.” from the report
Activities and relationships
People were offered a range of daily activities and were supported to keep in touch with relatives and friends.
“Activity coordinators planned and delivered activities to people on a daily basis.” from the report
Good food and health support
People were offered choices and special diets were provided where needed. Staff worked with health and social care professionals to support people's needs.
“Where staff supported people to eat and drink, this was undertaken with dignity and kindness.” from the report
Clean and well-maintained home
The home was clean and tidy. Staff followed infection control procedures and the premises and equipment were checked for safety.
“The home appeared clean and tidy and housekeeping staff followed cleaning schedules to ensure all areas within the home were regularly cleaned.” from the report
Medicines records
seriousInstructions were not always clear about giving medicines covertly. Liquid medicines did not always show when they had been opened, and one label did not show the medicine strength.
“People's medicine records and care plans failed to document guidance for staff on how each medicine should be given covertly.” from the report
Risk and pressure sore records
seriousSome care plans did not reflect people's current needs. Turning charts were not always completed as required for people at risk of pressure damage.
“turning charts in place were not completed as directed every 3 hours. This placed the person at further risk.” from the report
Management follow-up
needs fixingAudits had identified some of the problems, but the home had not dealt with them quickly enough. CQC recommended action plans to track whether improvements were completed.
“However, we were not assured that appropriate actions were taken in a timely manner to address these issues as they remain, and this requires further improvement.” from the report
Waiting for staff
needs fixingThe home used regular agency staff while recruiting. Some people said they sometimes had to wait because staff were busy or rushed.
“I sometime have to wait as staff have a lot to do” from the report
- 01What changes have been made to medicines records and instructions for giving medicines covertly?
- 02How do you now check that liquid medicines are labelled correctly and dated when opened?
- 03How are pressure sore care plans and turning charts checked to make sure they reflect people's current needs?
- 04What action plan is in place to make sure problems found in audits are fixed promptly?
- 05How many regular agency staff are currently being used, and how do you make sure people receive support without unnecessary waits?
This was an unannounced inspection that considered the care provided, the premises and all five CQC questions, including infection prevention and control; the three Good ratings remained Good from the previous comprehensive inspection. This explanation was written from the published report of 31 December 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, January 2021
Rated Good overall; inspectors found kind, responsive care, but medicines were not always managed safely.
This was an unannounced focused inspection on 26 November 2020. Inspectors looked at concerns about infection control and staffing, and also checked caring, responsiveness and leadership. They spoke with staff and relatives and reviewed six people's care records.
The home had enough staff and had good infection control arrangements during the COVID-19 pandemic. Inspectors found people were treated with kindness, dignity and respect. Care plans were personalised, activities were available and relatives generally spoke positively about the care.
Medicines management still needed improvement. Some medicine containers or devices were not labelled correctly, and one person's time-specific medicine was given late. Staff corrected the labelling during the inspection, and further training was arranged.
The overall rating improved from Requires Improvement to Good. Safe remained Requires Improvement. Caring, Responsive and Well-led were rated Good. Effective was not inspected at this visit, so its previous rating was used in the overall result.
Enough staff
Inspectors found adequate staffing on the day, with shifts covered and staff available to support people without appearing rushed.
“During the inspection staff did not appear to be rushed and were available to support people when needed.” from the report
Kind and respectful care
Staff used people's names, offered choices and explained care before carrying it out. People's privacy, dignity and independence were respected.
“During this inspection, we observed staff were kind and caring towards people using the service.” from the report
Personalised care
Care plans described people's preferences, cultural needs, health conditions and support needs. Records were updated when people's needs changed.
“People's care plans were person-centred and provided staff with guidance on how their needs should be met.” from the report
Infection control
The home had arrangements for testing, visitor checks, masks, handwashing, social distancing and protected visiting during the pandemic.
“People were protected from the spread of infection.” from the report
Improvement since the last inspection
Risk assessments, care records, dignity and privacy had improved. The home was no longer in breach of the earlier regulations identified in those areas.
“Since the last inspection, the service had made considerable improvements in relation to risk assessments, maintaining care documentation and ensuring people were treated with dignity and respect.” from the report
Medicine labels
seriousOne medicine container had the wrong person's name, and injectable medicine devices for two other people were not labelled. This created a risk of medicines being given to the wrong person.
“This meant there was a risk that medicines could be given to the wrong person or that staff would not know who they belonged to.” from the report
Time-specific medicines
seriousPeople receiving medicines at specific times were not always prioritised. One person's diabetes medicine was given 90 minutes late, although inspectors found no evidence of harm.
“However, people receiving time-specific medicines were not always prioritised and medicines were administered to people in room order rather than in accordance to people's needs.” from the report
- 01What extra training and guidance have staff received about time-specific medicines?
- 02How do you now check that every medicine container and injectable medicine device has the correct person's name?
- 03How do you make sure medicines for diabetes and other time-critical conditions are given at the prescribed time?
- 04What did your next medicines audit find after the inspection, and can we see the actions taken?
- 05How will you tell us if there is a medicines error or delay involving our relative?
This was a focused inspection of Safe, Caring, Responsive and Well-led; Effective was not inspected and its previous rating was carried forward. This explanation was written from the published report of 29 January 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 Fallowfield
10 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2021Goodup from Requires improvementSafe: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Requires improvementstayed Requires improvementSafe: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 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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