Fairglen Residential Home

Social Care Org · South West

Overall Rating
Inadequate Last inspected 25 November 2021
Domain Ratings
Safe
Inadequate
Effective
Inadequate
Caring
Inadequate
Responsive
Inadequate
Well-led
Inadequate

View Full CQC Report

17 must-do actions

Must-Do Actions (17)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider must operate an effective safeguarding system that reports and investigates concerns.
Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Safeguarding systems and processes did not operate effectively in the reporting and investigation of allegations of abuse. One person made an allegation of physical abuse about a staff member. The registered manager was aware of this but failed to report it to the local authority and investigate the matter further. …
Must Do
Safe
The provider must ensure safe care and treatment for people with epilepsy and follow dietary advice from professionals to prevent increased risk of harm.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Although some relatives told us they felt people were safe, our findings were that people were not safe and were at risk of avoidable harm associated with their assessed care needs. Where people were assessed as requiring equipment to reduce risks, the equipment was not in place. One person had …
Must Do
Safe
The provider must ensure people receive their medicine safely and implement systems that support safe and proper medicines management.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Medicines systems and processes did not always keep people safe. People's medicines support needs were not risk assessed, or care planned. Staff supported people to take their medicines but did not take their personal preferences into account about how or where they would like to take their medicines. There were …
Must Do
Safe
The provider must deploy staff effectively and ensure that care and treatment is provided by staff who have the right training to do so safely.
Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Staffing arrangements at night and during the day did not address the risks associated with peoples care needs. We observed one person who had previously been taken to hospital with a Injury to their head following a fall, this person was left unsupported whilst staff were asleep. If this person …
Must Do
Well-led
The provider must implement adequate systems to assess and improve the quality and safety of the service.
regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Systems were either not in place or robust enough to demonstrate accidents and incidents were effectively monitored and reviewed. The findings of our inspection identified a culture that was not based on learning. This meant that when things had gone wrong, the potential for re-occurrence was inevitable because there was …
Must Do
Safe
The provider must ensure that risks relating to infection control and the transmission of COVID-19 are being effectively managed.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
People were not protected from the risk and spread of infection. We were not assured that the provider was doing everything possible to prevent people, visitors and staff from catching and spreading infections. Whilst the provider had in place procedures for visitors entering the service, we found these were not …
Must Do
Effective
The provider must carry out an assessment of the needs for people.
Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
People's needs were not assessed. For example, two people who had recently moved to the service had not had their care needs adequately assessed. This meant, the provider had not ensured that staff had the skills and experience to be able to meet their needs safely and effectively. Daily records …
Must Do
Effective
The provider must provide adequate support and training to staff in order to meet people's needs.
Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Staff told us they had access to training and supervisions. However, the findings of our inspection demonstrated that staff support, and training was not effective. Staff had not received sufficient training to support them to deliver care effectively, in relation to positive behavioural support, mental health, capacity to consent, communication, …
Must Do
Well-led
The provider must implement effective systems to help ensure staff receive the required training and support.
Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The providers supervision policy stated, staff at Fairglen who supported people with a learning disability or autism, will be offered clinical supervision in addition to scheduled supervision. This was not in place and the registered manager was unaware of this until it was raised by the inspection team.
Must Do
Effective
The provider must take adequate steps to manage and mitigate risk in relation to people's weight loss.
Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
One person lost 25 kgs in weight over a 10 month period. Staff did not know when asked if the person had been referred to a healthcare professional to review their weight loss. There was no information within the persons care records to indicate that staff were regularly monitoring their …
Must Do
Effective
The provider must not unlawfully deprive people of their liberties whilst receiving care.
Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
A staff member described how three people would be prevented from leaving the service by themselves as it would not be safe for them to do so. The staff member confirmed that a Deprivation of Liberty Safeguards (DoLS) application had not been made to the local authority. There was no …
Must Do
Effective
The provider must ensure people are supported in line with the principles of the Mental Capacity Act 2005 (MCA).
Regulation 11 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
We reviewed the mental capacity assessment in relation to finance for one person. This person had been identified as lacking capacity in relation to managing their finances. The mental capacity assessment did not contain details to inform who was consulted or what their views were regarding the decision. The registered …
Must Do
Effective
The provider must ensure practices meet people's sensory needs and do not place restrictive measures on people without proper exploration and justification.
Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
During our inspection we observed that hand towels in toilets and bathrooms had been bolted to walls to prevent the hand towel being physically removed. The registered manager told us this was because one person kept taking them.
Must Do
Caring
The provider must ensure people are treated with dignity and respect at all times.
Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Although we observed some positive interactions between people and staff during the inspection, the language used by staff to describe the people they cared for within people's care notes and on occasions when speaking with us, was disrespectful, did not promote people's human rights or show they were valued. People …
Must Do
Responsive
The provider must ensure people receive care and support in line with their needs and preferences.
Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
We identified a poor culture where there were low expectations for people and an acceptance of situations and quality of life which would not be acceptable for most people. This was not in line with guidance contained in Right Support Right Care Right Culture. People were not supported to live …
Must Do
Well-led
The provider must ensure the quality and safety of the service is adequately assessed, monitored and improved to meet regulatory requirements and best practice guidance.
regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The providers oversight and governance of the service was inadequate in identifying the serious failings in relation to the safety, quality and standard of the service as detailed in the safe, effective, caring and responsive sections of this report. Records and checks undertaken by the registered manager and staff were …
Must Do
Well-led
The provider must inform CQC of notifiable events.
Regulation 18 of the Care Quality Commission (Registration) Regulations 2009
Services that provide health and social care to people are required to inform the Care Quality Commission (CQC), of important events that happen in the service. The registered manager was aware of their responsibilities, however had failed to inform CQC about reportable events. For example, one person had suffered an …

Previous Inspection (20 September 2018)

Rating: Good Type: Comprehensive inspection Actions: None
Location Details
CQC ID: 1-109006888
Local Authority: Plymouth
Region: South West
Inspection Report
Type: Comprehensive inspection
Date: 25 November 2021
Rating: Inadequate
Actions: 17 must-do
AI-extracted 17 Feb 2026