Fulford Care & Nursing Home

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 questiongood. At this inspection the key question has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. There was evidence of improved assessment processes to support safe admissions to the service. Accidents and incidents were reviewed for trends and to inform service improvements.

The provider did not always ensure continuity of care when people moved between different services. Before and during the assessment, people and their representatives told us they had not always received a timely or coordinated approach following discharge from hospital. This included delays in receiving specialist equipment and accessing community healthcare support. In response to concerns, the registered manager had introduced a more robust process to assess people’s needs prior to discharge, including completing assessments in hospital rather than over the telephone. This supported a clearer understanding of people’s needs and helped ensure safer discharges. Health and social care professionals told us this was an improving area, with better communication leading to more timely responses and improved outcomes.

Systems and processes were in place to share important information with others, such as ambulance and hospital staff, to promote consistency in care. Staff told us there were regular opportunities to discuss changes in people’s care and well-being to support people and their families through changes in their care journeys.

The provider worked with people to protect them from the risk of abuse. Safeguarding training was completed by new staff during induction and there was a system to ensure staff undertook refresher training. Staff we spoke with had an awareness of the signs indicating a person might be vulnerable to, or experienced, abuse.

Staff collaborated with people, families, and professionals to ensure people’s rights and freedoms were respected. Staff knew how to support people safely ensuring any restrictions to people’s liberty were necessary, lawful, and proportionate to the risk and seriousness of harm to that person. People told us they felt safe. Comments included, “Oh, yes. It’s a nice place.’ and “‘Yes, there’s always someone about.”

The provider did not always work well with people to understand and manage risks. Risk assessments and staff practice did not always ensure risks were managed safely or in a person-centred way. Care plans did not always guide staff to manage risks well and some risks about constipation, skin integrity, mobility and eating and drinking had not always been fully considered.

There was no evidence to suggest people had been affected negatively by these failings, however there was the potential for avoidable harm to occur. In response to our feedback the registered manager advised they would review risk assessments.

People told us they received support to reduce the risk of falls. One person said, “I’ve had falls, but they keep an eye on me. They look after me.” Equipment, such as sensor mats, walking aids, and bed rails were in place to help mitigate risks. A relative told us the service had been responsive in arranging a choking risk assessment for their family member. We also saw evidence of learning from incidents being used to reduce risks. For example, guidance wasintroduced to minimise the risk of scalding for a person who preferred black coffee, including instructions to add cold water before serving.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental risks were identified and mitigated to ensure peoples personal safety. This included key coded hot water urns, window restrictors, and key coded doors lawfully restricting entry to and from the dementia unit. There was a regular program of health and safety audit and checks, including those for gas, fire and water safety. Processes were in place to report and respond to building and equipment safety concerns in a timely way. Risk management processes were in place for emergency situations.

The provider did not always ensure staff had the skills and knowledge to support all people receiving care and treatment. Nursing staff demonstrated safe clinical practice and staffing levels were sufficient. However, the service supported 2 people with a learning disability. Staff had not received the required specialist training to support people with a learning disability. A senior manager told us plans were in place to roll this training out across the organisation. Both people had healthcare needs in addition to their learning disability, which, along with their support and communication needs, were being met in a person-centred way.

People gave mixed feedback about staffing. Some people told us there were several new staff who did not always understand their needs, which they found frustrating. Other people spoke positively about staff and told us, “Very efficient” and “All the staff, from the carers to the cooks are wonderful.” Some people told us call bell response times could be improved, a person said, “They don’t come that quickly. There’s never enough staff; you’re always seeing new faces here.” Other people said they did not have to wait long for support. A person said, “You don’t wait; they’re on the mark.” During the inspection, we observed call bells were responded to in a timely way and there were enough staff available to meet people’s needs.

Staff worked together well to provide safe care that met people’s individual needs. Safe employment processes protected people from the recruitment of unsuitable staff. Staff received a comprehensive induction which included mandatory training and observed practice and there were opportunities for staff development.

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. For example, the care home was closed to visitors for a couple of days in January 2026 to prevent a gastroenteritis outbreak from spreading. National good practice guidance for the correct handling of laundry was followed to prevent cross contamination from soiled linen and clothing.

Feedback from people and visitors on cleanliness was mixed. Some people reported unpleasant odours, while others described the home as immaculate. This aligned with our observations during the inspection. Some carpets and equipment were stained, and on the first day parts ofthe home appeared unclean with noticeable odours. By the second day, the environment was well-sanitised and smelled fresh. A cleaning programme was in place, with high-touch areas sanitised daily and other areas cleaned on a rotating schedule.

Staff had access to personal protective equipment (PPE). We observed staff used this appropriately when performing personal care, domestic duties, and food preparation.

Medicines and treatments were managed safely and in a person-centred way. The provider made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. People were consulted and informed about medicines changes. Medicines were administered by trained staff whose practice was supported by training and competency checks.

Medicines were ordered, stored, and disposed of safely, with enough stock available. Clear protocols, regular checks, and audits were in place. People told us their medicines were managed well, and those who wished to self-administer were supported to do so safely. Protocols were in place for ‘PRN’ (as required) medicines including those for pain relief.