Fairglen Residential Home

⚠ 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. …

⚠ 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 …

⚠ 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 …

⚠ 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 …

⚠ 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 …

⚠ 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 …

⚠ 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 …

⚠ 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, …

⚠ 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.

⚠ 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 …

⚠ 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 …

⚠ 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 …

⚠ 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.

⚠ 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 …

⚠ 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 …

⚠ 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 …

⚠ 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 …