Fairby Grange

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant the management and leadership was consistent. Leaders and the culture they created supported the delivery of high-quality, person-centred care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, and the needs of people and their communities.

People, relatives, visitors and those from the local community fed back positively in relation to the service and staff within the home. People told us, “The quality of the care is excellent” and “The service suits me down to the ground.” Relatives were equally complimentary saying, “I have found all the staff, from managers down to the most junior carers, to provide service in a very caring and attentive way. They treat each of the residents with great kindness, patience and a ready smile” and “From the moment he (their family member) arrived, the staff have been nothing but kind, attentive, and compassionate. It’s clear that everyone here genuinely cares about the well-being and comfort of the residents.”

Staff were observed displaying kindness and compassion in their interactions with people. Their approach was attentive and supportive, giving people reassurance. Staff said they enjoyed working at the service. us, “The residents are number one. I would never let anything happen to anyone. I couldn’t bear it if I didn’t do something” and “I like it here because it’s small and personal.”

The provider had senior staff at all levels who understood the context in which they delivered care, treatment and support.

Staff told us how supported they felt. One said, “[Manager] is fantastic to work with. We work well as a team” and “I have never met a person as genuine as owner [name].”

Although we received positive feedback about management, we found the provider needed to have better oversight of legislation, guidance and best practice to help ensure that all aspects of the service were being properly monitored and managed. This would help to identify any potential issues early on and improve the overall service quality.

Staff were given the opportunity to meet individually with their line manager to discuss their roles. In addition, regular staff meetings were held, giving everyone the opportunity to share ideas, suggest improvements, discuss the service and reflect on lessons learned. For example, a recent safeguarding concern was discussed amongst the staff team.

People also had opportunities to meet and provide feedback. From the notes of the most recent meeting, we read people had shared their views on the food, been consulted about work-experience students shadowing staff and were informed about a new key-worker scheme being introduced. Feedback was acted upon by senior staff and throughout our visit we observed management were visible, spending time with people and their relatives, supporting them and responding to queries.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff said they would be happy to raise concerns or worries and people, as well as their relatives told us senior staff were approachable and welcomed feedback. One person told us, “I rarely have a complaint, and I have not had anything serious so far, but I would speak to the manager or [provider] and I feel confident they would resolve it.” Relatives told us, “If I had any concerns, I would go straight to [manager’s name]. In fact, they encourage us to speak to them” and, “If there are any concerns I would 100% speak with management. There are good email communications and they are easy to approach.” A staff member said, “I would not hesitate. It wouldn’t worry me to report it (concerns). I would go to CQC and obviously there are places you could report abuse; you could report it to the police.”

Surveys were carried out for residents as well as staff. We read 14 responses had been received from the recent residents survey, with one person commenting, ‘Living here has been the happiest years of my life’. Where people had made comments that required action these were followed up.

Through the staff surveys, some staff had commented they would like the opportunity to undertake more training. We asked the provider how they had responded to this, and they told us, “There is a lot of staff training to do. In fact, there is a huge amount and we’ve always offered staff the opportunity to do more. But we’ll remind staff of that.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff undertook equality and diversity training and all staff from across the workforce knew one and another. A staff member told us, “Because it’s a small home we all work with each other at some point.”

The registered provider supported staff progression within the service. One staff member told us they had been promoted during the time they had been at the service. Senior staff also supported the team. We were told, “They will come and get their hands dirty. If [manager] says she will do something, she will. [Provider] is good. If you say something to her, she will do things to help you out.”

The service had a clear management structure with shared responsibility amongst the team.

While many improvements had been made to the systems and service since our last inspection, a few shortfalls remained. These included uncovered radiators, a lack of railings around a flat roof used as a fire escape and a lack of formal analysis of accidents and incidents. There was also the issue of the provider not following the principles of the Mental Capacity Act 2005 in relation to the CCTV. That said, these 3 issues were promptly addressed by the provider following our visit.

We did find some documentation was not contemporaneous. For example, one person was recorded as not having a fall in a year, but they had one in November 2024. This same person was susceptible to urine infections, yet this was not mentioned in their continence assessment. A second person was prescribed medication which could cause internal bleeding if they had a fall, even if they did not appear to be injured. Guidance was in place instructing staff to call 111 or 999 in the event of any fall, but accident and incident records showed that staff did not always follow this protocol. However, upon discussing this with the manager, we were informed the guidance was out of date and it was promptly amended.

Despite these shortfalls, we had no concerns that people were unsafe, or they received anything other than kind, compassionate and person-centred care. Staff had a clear knowledge of people and were able to describe specific information about the people they cared for. After our visit, the provider submitted an action plan outlining the immediate steps they had taken to address the areas we discussed along with additional measures, such as looking at a new electronic medicines system.

Other areas had improved due to action being taken following audits. For example, medicine reconciliation sheets were introduced following identification of incorrect medicine counts.

The provider understood their duty to collaborate and work in partnership with professionals and the local community.

Staff had established wide-ranging links with the community. People went regularly to a local community hub where they participated in activities and a singing group. Staff and people attended a twice-yearly event held at the local secondary school and they had linked up with another care home nearby to have inter-quiz competitions. The community warden worked closely with the service and regularly visited people. There were regular external outings organised by staff with the manager telling us, “We go out quite a bit. I don’t know what we would do without our (own) bus.”

In addition to community links, the service had a good professional relationship with their GP practice. The manager said, “GP rounds are more effective, as the communication between us has been strengthened.” Staff were also easily able to make referrals to other health care professionals to help ensure people received holistic care. The manager commented, “Paramedics or the care home visiting team will now come out.”

The provider focused on learning and improvement across the service and relatives spoke positively about this. One told us, “I have the impression that they (the provider) are continually looking for ways in which they can make changes that may have a positive impact on the lives of the residents.”

The manager had reviewed the structure within the workforce, telling us, “It’s more structured now. I have built a good rapport with the staff team and [staff name] was made up to deputy. We now have the manager, deputy and 4 seniors and the workload is shared between everyone. I’ve brought in trackers and audits are done on time. There is more time for management to do the care planning. We’ve also introduced resident of the day.” They went on to tell us, “I’ve also just finished and submitted the Gold Standard Framework (GSF) portfolio to improve the end of life care we provide.” The GSF is a practical and evidence-based end of life care service improvement programme.

Improvements had been made to the premises, with the manager telling us, “There is work being done on the roof. We’ve had a new boiler fitted and 2 new bathrooms done, as well as a shower room. The kitchen has been refurbished – it’s all stainless steel now. We are changing the carpet to flowing and we’ve been changing the beds.”