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CQC report explained · a residential care home, run by Voyage

Fairfax Road

19 Fairfax Road, Leeds, LS11 8SY

Goodpublished 9 January 2024, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People were protected from abuse and avoidable harm. Medicines, staffing, risk assessments, infection control and learning from incidents were found to be managed safely, although one medicines assessment was out of date.
Effective?
Good
This question was not inspected during this focused inspection. The rating from the previous inspection was used to calculate the overall rating.
Caring?
Good
This question was not inspected during this focused inspection. The report says care was person-centred and promoted people's dignity, privacy and human rights.
Responsive?
Good
This question was not inspected during this focused inspection. The rating from the previous inspection was used to calculate the overall rating.
Well-led?
Good
The provider had management and quality-checking systems, and acted on issues found during the inspection. A new manager was in post and had started the CQC registration process.
The latest report, explained

What inspectors found, January 2024

Rated Good; inspectors found safe, person-centred care, with some medicines and management records needing attention.

This was a focused inspection on 5 and 12 December 2023. Inspectors checked Safe and Well-led. They spoke with one person, two relatives and six staff, and reviewed care files, medicines records and management documents.

The home supported four people. Inspectors found people were safe, medicines were given as prescribed, staffing was sufficient and risks were assessed. Care promoted people's choice, independence, dignity and privacy. People and relatives spoke positively about the care.

The home had a new manager who had started the registration process with CQC. Inspectors found systems for checking quality and acting on improvements. Some issues were addressed during the inspection, including missing information about raising concerns and a medicines body map.

The overall rating was Good, as it was at the previous inspection in 2017. This inspection did not assess Caring, Effective or Responsive. Their earlier ratings were used when calculating the overall rating.

What inspectors praised
  • Safe medicines support

    People received their medicines on time and as prescribed. The provider also assessed how people could safely access medicines in their preferred way.

    People received their medicines on time and as prescribed.from the report
  • Enough suitable staff

    Inspectors found safe recruitment processes and enough suitable staff to support people.

    The provider ensured there were sufficient numbers of suitable staff.from the report
  • Person-centred care

    Staff knew people well and supported their choices, independence, dignity and privacy.

    Care was person-centred and promoted people's dignity, privacy, and human rights.from the report
  • Learning from incidents

    The home investigated accidents and incidents and shared learning with staff to reduce the chance of similar events happening again.

    Lessons were learned from incidents and learning was shared with the staff team to prevent similar incidents occurring.from the report
  • Quality monitoring

    The provider had systems to monitor care, identify improvements and check that actions were completed.

    There were systems to monitor the quality of the service to ensure improvements were identified and actioned.from the report
What inspectors were concerned about
  • One medicines assessment was out of date

    needs fixing

    One assessment about supporting a person to access medicines safely had not been reviewed on time. Inspectors raised this with the manager.

    We spoke with the manager to ensure these were reviewed regularly as we found 1 out of date.from the report
  • Information about raising concerns was briefly missing

    minor

    On the first inspection day, the noticeboard did not explain how people and staff could raise concerns. This was put back on display by the second day.

    On the first day of the inspection there was no information on the board on how this could be raised.from the report
  • Access to team meetings

    minor

    Inspectors discussed the need for regular team meetings so all staff could take part. The management team had booked several meetings.

    We discussed the importance of regular team meetings to ensure all staff could access these.from the report
Questions to ask them, based on this report
  1. 01How do you make sure medicines assessments are reviewed on time, including the assessment that was out of date at the inspection?
  2. 02How is the new manager's CQC registration progressing?
  3. 03How do you make sure every staff member can attend regular team meetings?
  4. 04Where can residents and families find information about how to raise a concern?
  5. 05How have you checked that the improvements made during the inspection have continued?

This was a focused inspection of Safe and Well-led only; the other ratings from the previous inspection were used to calculate the overall rating. This explanation was written from the published report of 9 January 2024 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.

The story over the years

Every inspection of Fairfax Road

3 rated inspections over 9 years: the service has held its Good rating throughout.

  1. January 2024Goodcurrent rating
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Fairfax Road

  2. February 2022Inspected but not rated
    Safe: Inspected but not rated

    We are reading this report · the original is on cqc.org.uk

  3. December 2020Inspected but not rated
    Safe: Inspected but not rated

    Read this report on cqc.org.uk

  4. July 2017Goodstayed Good
    Safe: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. February 2015Good
    Safe: GoodEffective: GoodCaring: OutstandingResponsive: Requires improvementWell-led: Good

    Read this report on cqc.org.uk

  6. May 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. August 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. November 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. December 2010

    Registered with the Care Quality Commission on 20 December 2010.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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