Fairby Grange

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Senior staff listened to and responded to concerns and accidents and incidents, but they did not formally record lessons learnt from these. The manager told us, “I sign them off (accidents and incidents), but I don’t do a formal analysis. It’s mostly in my head. I do an infection control log and look for themes in that, but I don’t do one for accidents and incidents.” However, staff carried out reflective practices where errors or incidents had occurred and additional training or changes to practices were made to help prevent reoccurrence.

For example, we reviewed recorded accidents and incidents and found that 25 falls had occurred during the last 16 weeks. Two people had experienced multiple falls during this time, leading to one being referred to the falls team (a group of professionals who provide support and guidance to help prevent hospital admissions due to recurring falls).

Staff shared information with each other to help ensure any incidents or accidents were known amongst the team. A staff member told us, “We get a handover every shift from the night before. You might have missed a fall, but they (colleagues) will tell you.”

Senior staff carried out pre-assessments with people and their families to help ensure a smooth transition from home or hospital into Fairby Grange. Relative’s told us, “We knew straight away it (the service) would be ideal for [relative]. From the day she moved in she’s been happy there” and, “We are confident that she is in the right place and receiving the best care.” A community professional told us, “As a professional working with the village, I have always found Fairby Grange to be very welcoming and supportive to me in my role, especially with supporting families and individuals with their transition from home to Fairby.”

The manager carried out assessments with people prior to them moving in. This was to check Fairby Grange was able to offer them the care they required. They told us, “I always do an assessment face to face.” The information gathered during the pre-assessment formed the basis of the person’s care plan enabling staff to read about the person, their needs, likes and dislikes.

Senior and care staff understood their responsibilities in relation to safeguarding people from abuse or avoidable harm. Staff received safeguarding training and there was information available to them on who they could report any concerns to. Staff said, “I would report it straight to [manager]. I would always report anything”, “I would report to [senior staff]. I would not hesitate and, “Safeguarding training is repeated every year. I feel confident in identifying signs of abuse/neglect and escalating them.”

Relatives felt their family member was safe living at Fairby Grange. One told us, “I never mind leaving her.” Another said, “The team is always patient and understanding, taking the time to ensure he feels safe.”

We checked whether staff were meeting the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Safeguards procedures. We found that although capacity assessments and best interests decisions had been made for a range of potential restrictions, this has not been done for the CCTV that was used in the service. The provider told us, “It is in our Statement of Purpose which we give to people when they move in and we have a sticker on the front door.” Whilst CCTV can be used in areas of a care home, it may impact on a person’s human rights. Procedures must be followed to ensure that CCTV is the least restrictive and most appropriate option for maintaining safety. The provider started completing capacity assessments for people immediately following our visit.

Staff worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Previously we had found staff were not checking people’s mattresses properly to ensure they were appropriate and supported people in a way to reduce the risk of their skin breaking down. At this inspection, people’s mattresses were checked regularly by staff and we observed they were set at the correct pressure.

People were provided with equipment and assistance to help them mobilise in a safe way. We observed staff supporting people to walk. With one person, staff were gently assisting them with encouragement but without rush.

People had a wide range of risk assessments which had been regularly reviewed in their care plans. These set out steps for staff to take to mitigate potential risks. They included high risks in relation to falls, nutrition and hydration as well as fire risks from emollient creams. One person was observed to have a reduced appetite and weight loss recently and as such staff had made a referral to a specialist service and were monitoring their food intake and weight. One person often refused to be weighed and a risk assessment was in place for this. Additionally, a second person stayed in bed, so staff used a recognised method of measurement of their upper arm to monitor their weight.

Senior staff detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Relatives felt the environment was being improved by the provider. One told us, “During the relatively short time that my mother has been a resident, I have seen a number of improvements being made to the facilities.”

Several checks were conducted at the service to ensure it was safe for people. However, we identified two concerns - a fire escape that led onto a roof without railings, and some uncovered radiators. We discussed these with the provider and reviewed the fire risk assessment carried out in March 2025. The provider immediately ordered radiator covers, and the fire risk assessment had not highlighted any issues.

Weekly checks were carried out on the fire alarm system, as well as on water temperatures, window restrictors and pressure mattresses. Annual servicing was conducted for the stair lift, hoists, call bell system and air conditioning.

The manager made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. The manager used a dependency tool to assess, review, and reassess people’s needs to help ensure appropriate staffing levels. People and their relatives told us they felt there were enough staff available. One person said, “You only have to ask and it’s done for you.” Another told us, “There is always someone around.” Relatives fed back, “The staff are attentive. You don’t have to wait long when you ring the bell”, “Staff are attentive and spot on. Her needs are tailored to” and “Each and every carer is very hardworking and they are always very professional.”

Staff felt there were enough of them on duty each day. They told us, “We always try to have someone in the lounge”, “Sometimes staff have to do the domestic duties, which can take them away from the residents, but recently [registered provider] has got a cleaner to stay later” and “I feel we do have enough levels of staff. We always have cover if people are sick, and we have a group of staff who offer to cover shifts.”

Staff received a range of training in preparation for their role. This training was refreshed regularly, and staff had the ability to request specific training if required. Staff were also meeting best practice guidelines by completing role-specific, relevant training. The manager told us, “For those who have been in care for a while, they are completing their NVQ Level 2, however, for staff new to care, they are undertaking the Care Certificate.” The Care Certificate is a set of agreed standards for health and social care support workers in the UK.

Staff were supported through supervision and appraisal. This gave them the opportunity to meet with their line manager on a one-to-one basis to discuss performance, training requirements or concerns.

Staff were recruited through a robust recruitment system. This included providing references from their previous employment, confirmation of their right to work in the UK and their fitness to work in the role. Each prospective staff member underwent a Disclosure and Barring Service check. This helped ensure staff are suitable to work with people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service was clean and well maintained. Some bathrooms as well as the kitchen had recently been refurbished. This had resulted in them being more suitable spaces for people and staff to use as well as easier to clean.

Throughout the day, we observed housekeeping staff at work and people told us they were happy with the environment and its cleanliness. Relative’s told us, “When I’ve been up to her room, it has always been clean” and “The home is always spotlessly clean. Her room is always immaculate too.”

People received the medicines they required and where possible, people were supported to manage their medicines themselves. This helped encourage people’s independence and control. One person said, “I am able to administer them myself, including topical creams (medicine in cream format). Staff encourage me to manage them independently.” Relatives had no concerns about this aspect of their family member’s care. A relative told us, “Her (their family members) medicines are fine. There was an issue when she first came (not related to Fairby Grange) and they sorted it straight away. They check if she is pain free. They have done more for her in terms of the pain in her back than anyone else.”

The service used an electronic medicines administration system which although alerted staff if medicines had not been given, did not always support them with other good medicine management practices, such as with the placement of pain patches (medicines in patch form). The deputy manager explained, “The system only shows the last position the patch was placed, but staff need to see the last 3. I have introduced a paper system for staff to complete instead.” Although the deputy manager had addressed this, we found gaps in the records, creating a risk that staff might not know where to place a new pain patch if one fell off. However, staff were knowledgeable about checking when a patch was last applied and spoke confidently about correct application and rotation practices. One told us, “On the system we have a body map that highlights where you put the patch. We do daily checks too. The system prompts you.”

In addition, where people were on, ‘as and when’ medicines, the electronic system did not facilitate staff storing PRN protocols on it or writing if the medicine was effective. The deputy manager told us, “The people who run the medicines system don’t get back to you or support us, so I am re-writing all of the PRN protocols.” Immediately after our inspection, the provider arranged to look at an alternative medicines system which would be more efficient.