CQC report explained · a residential care home
What the CQC found at Fairby Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Fairby Grange rated Requires Improvement; inspectors found kind, responsive care but gaps in medicines, risk management and oversight.
Inspectors visited unannounced on 23 and 24 August 2022. They spoke with people, relatives and staff, reviewed care and staff records, observed medicines being given and checked infection control.
The home was rated Good for Effective, Caring and Responsive. People were treated kindly, supported to make choices, helped with food and healthcare, and offered activities and contact with relatives.
Safe and Well-led were rated Requires Improvement. Inspectors found medicines were not always stored correctly, some records and risk assessments were incomplete, some staff did not wear masks correctly, and night staffing might not have been enough for a fire evacuation.
The overall rating remains Requires Improvement, the same as at the previous inspection. The home remained in breach of Regulations 12 and 17. The provider took some immediate action, but CQC asked for an action plan and will monitor progress.
Kind and respectful care
People and relatives described staff as kind and respectful. Inspectors saw staff protecting privacy and dignity and supporting people in a person-centred way.
“The interactions between people and staff were positive, caring and inclusive.” from the report
Better personalised care planning
The home had introduced electronic care planning with information about people's preferences, history and assessed needs. Responsive care improved from Requires Improvement to Good.
“Since our last inspection in December 2019, the provider had introduced an electronic care planning record, which was person-centred” from the report
Food and healthcare support
People received food and drinks suited to their needs and were supported to see health professionals. Staff followed specialist advice about food textures.
“Food and fluid met people's assessed needs.” from the report
Activities and relationships
People could take part in group or individual activities and were supported to maintain relationships that mattered to them.
“People could participate in group or one to one activities.” from the report
Medicines safety
seriousSome medicines were stored above 25 degrees, which could affect their effectiveness. One handwritten medicine record was not always checked and signed by two staff, and two people's medicines were recorded as being given at the same time despite advice that they should not be taken together.
“Medicines had not been stored at the correct temperature to ensure they were safe to use.” from the report
Incomplete risk assessments
seriousSome people with diabetes did not have guidance about blood glucose ranges or what to do if readings were abnormal. Some people taking blood-thinning medicines also lacked assessments describing safe ways of working.
“Risks to people had not always been identified to ensure staff had the guidance necessary to follow a specific plan to prevent harm.” from the report
Night staffing and evacuation
seriousThere might not have been enough staff at night to meet people's needs and evacuate them safely during a fire. The provider said it would increase night staffing from two to three staff and was referred to Kent Fire and Rescue Service.
“There may not be enough staff deployed on night shifts to meet people's needs and to safely evacuate people in the event of a fire.” from the report
Infection control practice
needs fixingSome staff were not wearing masks over both their mouth and nose. CQC was only somewhat assured that personal protective equipment was being used effectively and safely.
“We observed some staff were not always wearing masks appropriately (over their mouth and nose) when working.” from the report
Mattress checks
seriousMattress checks were not regularly recorded. One mattress was not inflating correctly and another was set for the wrong weight, creating a risk of pressure ulcers.
“Mattress checks were not regularly documented and recorded to show that staff were ensuring the mattresses were working correctly and set at the correct setting.” from the report
Weak management checks
seriousAudits had not identified the medicines, risk assessment and staffing problems found by inspectors. This meant the home could not show that quality and safety were being managed reliably.
“The governance of the service continued to be not sufficiently robust.” from the report
- 01Have medicines now been stored within the correct temperature range, and how is this checked and recorded each day?
- 02What is now in place for people with diabetes or taking blood-thinning medicines, and how do staff find and follow these risk assessments?
- 03Are there now three staff on every night shift, and has a fire evacuation drill confirmed that this is enough?
- 04How are mattress settings and daily mattress checks recorded, and what happened after the mattress problems found during the inspection?
- 05What changes have been made to management audits so they identify medicines, risk assessment and staffing problems before CQC does?
This was an unannounced follow-up inspection covering all five key questions, prompted by concerns about safety and following up action from the previous inspection; infection prevention and control was also checked under Safe. This explanation was written from the published report of 26 October 2022 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.
What inspectors found, March 2020
Rated Requires Improvement; inspectors found kind and effective care, but medicines, risk records and care planning were not always safe or reliable.
This was an unannounced inspection on 11 December 2019. One inspector and an expert by experience spoke with people, relatives, staff, the manager and a visiting physiotherapist. They observed care and checked care records, medicines, staff files, incident records and quality checks.
The home was rated Good for Effective and Caring. People said they felt safe, staff were kind, there were enough staff, and people had access to food, activities and healthcare.
The overall rating was Requires Improvement. Medicines were not always managed safely. Some risk assessments and care plans were missing or out of date, and audits did not reliably find these problems. The home breached regulations on person-centred care, safe care and treatment, and good governance.
The rating had fallen from Good at the previous inspection, published on 10 May 2017. The manager took some action during and after the inspection, but CQC said it would check whether improvements were fully completed at a future inspection.
Kind and respectful staff
People and relatives described staff as kind and caring. Inspectors saw staff spending time with people, respecting privacy and asking before giving help.
“We observed staff interacting positively with people.” from the report
Enough staff
Inspectors found enough staff to meet people's needs in a timely way. People said they did not have to wait for help.
“There were sufficient numbers of staff on duty to meet people's needs in a timely manner.” from the report
Training and support
Staff had induction, training, supervision and appraisals. The required training listed in the report was up to date.
“Staff were supported through induction, training and supervisions.” from the report
Activities and independence
People were offered varied daily activities, including exercise, trips and entertainment. Their choice not to join in was respected, and some people were supported with volunteering and a holiday.
“A variety of activities were delivered to people on a daily basis.” from the report
Choice and consent
Staff followed the Mental Capacity Act principles, sought consent and involved people in decisions about their daily support.
“People were encouraged to make decisions for themselves and were provided with information in a format that met their needs.” from the report
Medicine safety
seriousMedicine records had unexplained gaps, liquid medicines were not always dated when opened, and some prescribed creams were not securely stored. Staff medicine competency checks and audits did not find these problems.
“Medicine Administration Record (MAR) charts were not always signed and there were no notes recorded as to why this was the case.” from the report
Care plans not kept current
needs fixingCare plans did not always reflect changes in people's needs or explain how to reduce risks. One person's care plan was not updated after a fall and minor injury.
“Care plans were not always reviewed regularly, staff did not always identify when people's needs changed and their care plans had not always been updated.” from the report
Weak quality checks
seriousThe home's audits were not robust enough to identify problems with medicines, care plans, risk assessments and learning from incidents. This contributed to a breach of the good governance regulation.
“The governance of the service was not effective or robust and this was evidenced by the nature of the breaches of the regulations we identified at this inspection.” from the report
- 01How are you checking that every medicine administration record is complete and that any missed dose has an explanation?
- 02How do you assess and manage choking, falls and call bell risks for each person, and how quickly are plans updated after a change or incident?
- 03What weekly medicine audits and care plan audits are now completed, and can we see evidence that they identify and fix problems?
- 04How do you make sure lessons from accidents and incidents are recorded and shared with all staff?
- 05What action has been taken since the inspection to meet the three breached regulations?
This was an unannounced planned inspection covering all five CQC questions, including care, premises, records, medicines, staffing and management systems. This explanation was written from the published report of 12 March 2020 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.
Every inspection of Fairby Grange
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2020Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015
Registered with the Care Quality Commission on 21 September 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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