About the service:

Fairhaven is a residential care home that was providing personal care to 21 people aged 65 and over at the time of the inspection. People living at the home had a range of care needs, including people living with dementia.

People’s experience of using this service:

• At the last inspection in December 2017 we found risks to people were not always effectively managed. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and provider was required to make an action plan for improvement. At this inspection we found improvements had been made and there were effective systems in place to respond to incidents, which included reporting to the local authority where appropriate.

• At the last inspection we also identified concerns around the homes governance, and found systems did not ensure the quality and safety of the service was assessed, monitored and improved. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and we told the provider to take action. During this inspection we found quality assurance was effective, and the registered manager completed regular audits to identify concerns and drive improvements in the quality of care delivered.

• Risks to people and the environment were effectively managed though robust assessments and people were appropriately protected from the risk of abuse and avoidable harm.

• People and relatives told us they were happy with the care and support provided at Fairhaven.

• People were supported to receive personalised care to meet their needs and care records were person-centred to reflect people’s likes, dislikes and preferences.

• People and relatives were involved in the planning and delivery of their care, and the registered manager sought regular feedback from people.

• People were supported to receive their medicines safely and in a timely manner by staff who were appropriately trained for their roles.

• People’s rights and freedoms were upheld and staff treated people with dignity and respect.

• People were encouraged to make their own choices and decisions as appropriate, and where people required additional support with this staff followed best practice guidance and legislation to support them.

• People had access to a range of activities to meet their interests, which were flexible to meet their individual needs.

• The service met the characteristics of Good across all areas. More information can be found to evidence this in the full report.

Rating at last inspection:

This service was previously rated as Requires Improvement at the last comprehensive inspection. This report was published on 22 February 2018.

Why we inspected:

This was a planned inspection based on the previous inspection rating.

Follow Up:

There is no required follow up to this inspection. However, we will continue to monitor the service and will inspect the service again based on the information we receive.

Fairhaven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Fairhaven accommodates up to 21 people in one adapted building. At the time of our inspection 19 people were living at the home.

This is the first inspection since Oakray Care (Fairhaven) Limited was registered to provide the service in June 2017.

This inspection took place on 14 December 2017 and was unannounced. We returned on 21 December 2017 to complete the inspection.

There was a registered manager in post at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

The systems for responding to incidents and reporting to the local authority safeguarding team were not always followed effectively. The registered manager was not aware of some incidents that had happened and action had not always been taken to review the care provided to people to minimise the risk of incidents happening again.

On the first day of the inspection we found that the systems to identify and manage other risks people faced were not always effective. Action had not always been taken to ensure staff had clear information about how to minimise the risks to people. By the second day of the inspection the registered manager had taken action to address the concerns regarding risk management.

On the first day of the inspection we found decisions taken on behalf of people who did not have mental capacity did not always follow the principles of the Mental Capacity Act. By the second day of the inspection the registered manager had taken action to ensure they met their legal responsibilities when making decisions on behalf of people.

Whilst the registered manager had taken action following the first day of the inspection, action was needed to ensure the improvements were sustained and embedded in practice.

The governance systems were not effective at ensuring the provider met their legal obligations and the service made any necessary improvements. Oakray Care (Fairhaven) Limited had been the provider of the service since June 2017. The registered manager reported that visits to assess the service by one of the directors of Oakray Care (Fairhaven) Limited had taken place on several occasions, but they had not received any feedback from the visits. The registered manager was not aware whether there were actions they needed to complete following the visits.

The registered manager completed a number of internal audits in the service. However, these audits had failed to identify the concerns identified in this inspection. The governance systems did not ensure the quality and safety of the service was assessed, monitored and improved.

People who use the service and their relatives were positive about the care they received and praised the quality of the staff. Comments from people included, “Without a shadow of a doubt they look after [my relative]. She wouldn’t be with us unless she lived here”; “Staff are very good. They have looked after [my relative] extremely well” ; “I have been very happy with the care provided”. We observed staff interacting with people in a friendly and respectful way. Staff respected people’s choices and privacy and responded to requests for assistance.

People told us they felt safe when receiving care and were involved in developing and reviewing their care plans. Medicines were stored safely in the home and staff had received suitable training in medicines management and administration. People received the support they needed to take their medicines. There were sufficient staff availabl