Fairby Grange

Updated 26 October 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

Fairby Grange is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Fairby Grange is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 23 August 2022 and ended on 24 August 2022. We visited the service on both dates.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We sought feedback from the local authority and professionals who work with the service. We received feedbacks. We used all this information to plan our inspection.

During the inspection

We spoke with four visiting relatives and 14 people who used the service about their experience of the care provided. We spoke with nine members of staff including, care workers, senior care workers, cook, the registered manager and the provider. We reviewed a range of records. This included five people's care records, and three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. We observed medicines administration round. We continued to seek clarification from the provider to validate evidence found.

Updated 26 October 2022

About the service

Fairby Grange provides accommodation and personal care for up to 27 older people. The service provides both permanent and respite support. There were 18 people living at the home on the day of our inspection.

People’s experience of using this service and what we found

Medicines had not always been stored at the correct temperature to ensure they were safe to use. Medicine administration record (MAR) charts for one person had not always been checked and signed off by two staff to make sure the MAR had been completed accurately according to the prescriber's guidance. The registered manager took immediate action to rectify this.

Risks to people had not always been identified to ensure staff had the guidance necessary to follow a specific plan to prevent harm. Risk assessments were not always in place to detail safe ways of working with some people with certain condition such as people prescribed blood thinning medicines. The registered manager took immediate action to rectify this.

We found that staff were not always adhering to government guidance on Covid-19. We observed some staff not wearing masks or not wearing them correctly in the service.

There were enough staff to meet people’s needs during the day. However, we found there may not be enough staff at night in case of fire evacuation. The provider responded by recruiting additional night staff.

The governance of the service was not robust enough. Although improvements had been made, we found areas that require further improvements.

Staff supported people and ensured they were safe. Staff recorded accidents and incidents and ensured preventative measures were implemented.

People received support with their food and fluid needs. One person said, “We get good food and offered choices. We get to choose a day before.” The home was adapted and designed in line with people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were supported by kind and caring staff. Staff treated people with respect and ensured people’s privacy was maintained. People were treated with dignity.

People had access to a range of activities to suit their needs and preferences. People were encouraged to maintain relationships with relatives and new friendships in the home were promoted. For example, we met three ladies who told us, “Lovely here. We have made friends here.”

People felt included in the running of the home. Staff received regular supervision and took part in staff meetings. This meant they felt comfortable to raise any concerns or suggestions in relation to the care provided.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 12 March 2020). The service remains requires improvement.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about incidents and accidents reporting, safeguarding, medicines, infection control, staff trainings, risk assessments and compliance with fire regulations. A decision was made for us to inspect and examine those risks.

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified two breaches in relation to, safe care and treatment; medicines management and robust monitoring of the quality and safety of the service.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.