Foxburrow Grange

Foxborrow Grange is a residential care home providing personal and nursing care to up to 69 people across 4 separate wings, 2 wings specialise in providing care to people living with dementia. At the time of our inspection there were 58 people using the service.

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

A small minority of people using the service had a learning disability. The registered manager told us their primary care needs were nursing. However, we expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. Based on our review of the effective and responsive key questions, the service was able to demonstrate they were meeting some of the underpinning principles of the Right support, right care, right culture guidance. All staff had completed training for people with a learning disability and autistic people. The service had implemented tools, such as social stories, designed to help people with a learning disability to process a particular situation, event or activity. People had been referred to the speech and language team (SaLT) team to be assessed for equipment and, or methods to help them communicate.

Systems were in place and being used for managing safeguards, but on occasion they were not given sufficient priority, or reported to the local authority for advice, as per the provider’s own guidance.

Systems to identify and address potential risks to people using the service, had improved. Management and staff had worked well with the dementia specialist team to develop a risk-based approach to effectively support people whose behaviour can sometimes present a risk to themselves, or others. Routine checks were now being carried out on clinical equipment, bed rails and wall bumpers to ensure these were safe and in good working order. However, further improvements were needed to ensure electrical sockets were assessed against the risks of tampering with and the risk of electric shocks or burns.

People were supported to eat and drink enough to maintain a balanced diet. However, staff did not always have access to up to date and reliable information about peoples’ specific dietary needs and choking risks. Whilst no people had come to harm, where changes had been made to their diets, such as changes in the size, texture or consistency of foods and fluids, these had not always been updated in their care records in a timely way. Therefore, staff did not always have the correct information to support people to eat and drink safely. Immediately following the inspection, the registered manager told us they had reviewed people’s records to ensure they contained accurate information. They had also sought additional training through the SaLT team for all staff, including catering staff to improve their understanding of managing dysphagia.

Staffing levels were reviewed on a regular basis to ensure there were enough staff deployed across the service. However, we observed, and staff told us, they struggled to meet the changing needs of people in Hedgehog unit. The registered manager agreed to review staffing numbers on Hedgehog unit to ensure people received timely care and support.

The service had made significant improvements to the management of medicines. However, improvements were needed to make sure people prescribed time sensitive medicines were given these within the recommended time frame. We have made a recommendation about following national guidance for administration of medicines.

Staff were recruited safely. Staff had received support, induction and training they needed which gave them the skills and knowledge to meet people’s needs. The service worked well with other professionals to understand and meet people's needs. Staff supported people to live healthier lives, and access healthcare services. A ‘Smiling Matters’ approach had been implemented to promote people’s oral hygiene.

Peoples' privacy, dignity and independence was respected. 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’s risk assessments and associated care plans needed further development to ensure they were current, reliable, and relevant. Summary and extended care plans contained repetitive information which had the potential to cause confusion and/or error in the delivery of people’s care. We have made a recommendation about care planning.

Staff were not always responsive to people’s needs. People told us, and records showed staff response to managing pain, was not always dealt with quickly enough. The registered manager had recognised improvements were needed in relation to end of life care. They were working with their local

hospice developing training and support for all staff to improve advanced care planning, communication, and having uncomfortable conversations about death and dying.

Our previous inspection found the leadership and governance systems to assess and monitor the quality and safety of the service were ineffective. At this inspection we found Improved auditing process, including a monthly governance report which were identifying where improvements were needed, and the action taken. However, further improvements were needed to ensure governance systems encompassed the wider quality and safety issues we identified during this inspection. This included staffing levels / deployment of staff / quality and accuracy of information about people’s care needs and how they are to be supported.

We have made recommendation about quality assurance arrangements.

Improved analysis of incidents and accidents had led to a decrease in falls. Investigations into incidents to establish the cause were completed and learnt from to improve safety across the service.

Information received before and during the inspection reflected ongoing concerns about a poor culture across all departments. This focused on unsupportive management, and a lack management presence on the floor. Work was in progress in conjunction with the provider’s human resources to reach out to staff to improve morale, communication, and effective team working.

The management team had developed a range of ways to engage with people, their family, friends, and staff in a meaningful way. These included feedback from questionnaires, a family forum and a twice monthly newsletter to keep people and their relatives informed of any changes in the service and upcoming events.

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

Rating at last inspection and update

The last rating for this service was inadequate. (Published April 2023). 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 improvements had been made and the provider was no longer in breaches of regulations in relation to safe care and treatment, failure to protect people from unnecessary control and restraint, including the excessive or inappropriate use of medicines, and governance arrangements.

This service has been in Special Measures since 26 April 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, responsive, and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for Foxburrow Grange on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Foxborrow Grange is a residential care home providing personal and nursing care to up to 69 people across 4 separate wings, 2 wings specialise in providing care to people living with dementia. At the time of our inspection there were 63 people using the service.

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

People’s relatives told us they felt their loved ones received good care and were safe. However, we found people’s care and support was not always planned in an individualised or personalised way. The care provided was not always responsive to the requirements of people with more complex needs.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. Management and staff did not recognise unnecessary control as restraint, including during personal care or inappropriate use of medicines which placed people at risk of harm.

Systems to identify and address potential risks to the health, safety and welfare of people were not effective. Risks to people becoming asphyxiated due to having bed rails or obtaining skin tears from metal brackets fixed to wall to protect damage from the bedhead had not been adequately assessed. People’s records contained insufficient information about risks associated with medical conditions. Individual fire risk assessments and evacuation plans had not considered all factors to affect a safe evacuation for the person in the event of a fire.

Systems in place to ensure the safe administration, ordering, storing and recording of medicines were poor, which placed people at risk of harm.

Systems to protect people from behaviour that presented a risk to themselves, or others was ineffective. Staff had not been provided with the training they needed to meet the specific needs of people using the service, including how to recognise and de-escalate early signs of distress or effectively manage people’s heightened anxiety.

Recruitment practices needed to improve to ensure all relevant documentation was obtained to ensure fit and proper staff were employed to work with people using the service. Staff were not routinely provided with appropriate supervision and appraisal to enable them to carry out the duties they were employed to perform and ensure they were competent to meet people’s specific needs.

The service used the Montessori Approach adapted for older people who are living with dementia. This approach promoted individualised care to enable people to get the most out of each day. We did not always see evidence this approach was being applied or how it improved outcomes for people. We saw and records showed there continued to be high levels of people’s behaviour escalating due to increased anxiety and distress being managed via sedative medicines. There was an abundance of group activities for people who were able to participate, however further consideration was needed to improve the experiences of people with more complex needs on an individual basis to promote their well-being and meet their emotional needs.

The registered manager told us a small minority of people using the service had a learning disability. We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of the effective key question, the service was not able to demonstrate how they were meeting some of the underpinning principles of the Right support, right care, right culture guidance. This was in relation to overuse of medicines to manage people’s behaviour and the size of the care setting, which as a larger service is not in line with usual best practice for accommodating people with a learning disability. The registered manager was not aware of this guidance but informed us the primary care needs of those people with a learning disability was nursing. They told us they would ensure they were up to date with the guidance. From 1 July 2022, all registered health and social care providers must ensure that their staff receive training in learning disability and autism. Staff had been assigned to complete this training.

People were supported to eat and drink enough to maintain a balanced diet. Staff supported people to access healthcare services and support when needed. The provider had embraced technology, including trials of a new falls system being installed to reduce falls. Infection prevention and control was being well managed keeping the premises clean and preventing outbreaks of infections.

We found the leadership, governance and culture did not support the delivery of high-quality, person-centred care. Systems to assess and monitor the quality and safety of the service were ineffective. Auditing processes did not provide an accurate overview of the service; ensure proper monitoring and review, identify shortfalls or inform an ongoing plan for improvement. Information from incidents, investigations and complaints were not learned from and used to drive improvement. Whilst it is recognised the registered manager took immediate action to make improvements, following the inspection, the governance arrangements had failed to identify the compromised quality and safety of the service.

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 good (published 11 February 2021)

Why we inspected

This inspection was prompted by a review of the information we held about this service. We received concerns in relation to the management of service and a lack of falls management resulting in injuries. As a result, we undertook a focused inspection to review the key questions of safe and well led. During the inspection we found there were concerns in other areas of the service, so we widened the scope of the inspection to become a comprehensive inspection which included the key questions of safe, effective, caring, responsive and well-led.

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.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well led relevant key question sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Foxborrow Grange on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, failure to protect people from unnecessary control and restraint, including the excessive or inappropriate use of medicines and governance arrangements at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Foxburrow Grange is a care home is a residential care home providing personal and nursing care to up to 69 people aged 65 and over. At the time of the inspection there were 63 people living at the service.

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

The manager had made positive changes since their arrival, these improvements need to be sustained to demonstrate management stability across the service. The feedback we received during our inspection combined a positive view of the new manager, with an anxiety that some changes would have a negative impact on the care given to people.

Audits were undertaken by the manager. However, during an audit process it had not been picked up that some medication was in fact out of date and would not be able to be given to the person if they required it. We have made a recommendation about this. We discussed our findings with the manager and deputy manager and were assured this was remedied immediately.

The manager had a practical, person-centred approach which was making a difference to the care people received. Feedback was particularly positive about how well and open the manager was communicating with people, families and staff.

We found care was well-planned and staff minimised risks to people’s safety. The administration of medicines was carried out safely.

There were enough staff to keep people safe. The manager was working well with the staff team to improve staff turnover, morale and skills.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The manager promoted a person-centred approach to managing restrictions resulting from the COVID-19 pandemic. They communicated well with people and families to explain restrictions.

Infection control and prevention measures were in place and we were assured the service had systems in place to respond to coronavirus and other infection outbreaks effectively. Staff were clear of safeguarding processes, and when and how to raise concerns.

Senior staff carried out regular checks on the quality of care and took action which directly improved care standards.

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

Rating at last inspection

The last rating for this service was Good (published 23 March 2018). The overall rating has remained the same Good.

Why we inspected

We had received some concerns from whistle-blowers due to the change of management and how this had a negative impact on the care given to people living in the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We found no evidence during this inspection that people were at risk of harm from this concern.

We reviewed the information we held about the service. No areas of concerns were identified in the other key questions. we therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this 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 had been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Foxburrow Grange on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our last inspection on 10 March 2017, we found the provider to be in breach of multiple regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found incomplete risk assessments and a lack of clear guidance for staff about how to manage risks and mitigate the potential of reoccurrence. Staff did not always understand their responsibilities to ensure people were given choices about how they lived their lives and consent to care was not always sought in line with current legislation. People’s food and fluid intake was not always accurately monitored to ensure that they were protected from the risk of dehydration. Staff had not completed essential training or received annual appraisals and did not have access to regular supervision to support their professional development. The provider and failed to maintain a clear oversight of the service. We gave the home an overall rating of requires improvement and rated the area of effective as inadequate. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the quality of the service.

At this inspection, we looked to see whether the provider had implemented the action plan. We found the provider had made the required improvements to improve the standard of care and they were no longer in breach of any regulations. Since the last inspection, the provider had appointed a new registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Following the previous inspection improvements had been made to people’s risk assessments. They now reflected people’s needs and contained clear guidelines for staff to protect people from harm. Staff received training on how to recognise signs of abuse and were clear about what action to take if any concerns arose.

Staff sought consent before providing care and consistently worked in line with the legislation of the Mental Capacity Act 2005 and no unnecessarily restrictive practices were in place. Since the previous inspection, the service had commissioned a new training provider to deliver training to staff on how to support people with dementia who may be resistive to personal care; In addition, one-page profiles highlighting key risks and how best to support people were in each person’s daily files.

Staff had completed a variety of training sessions. This meant people received care from skilled staff who were able to meet their needs. Staff received supervision and annual appraisals to support them in their role and identify any learning needs and opportunities for professional development.

Staff had completed nutritional assessments. Where people were found to be at risk of malnutrition or a low fluid intake this was clearly recorded in their care plans, and staff effectively monitored and recorded their food and fluid intake. Where staff had identified concerns about people’s nutritional status specialist advice was sought from healthcare professionals such as the dietician and speech and language therapist.

The service had a robust recruitment process in place to ensure that staff had the necessary skills and attributes to support people using the service. New members of staff completed an induction programme during which they completed training sessions and were introduced to, and spent time with, the people that they would be supporting.

Staff provided people with individualised care, which was centred on their needs and wishes. The care and support provided to people was based upon their preferences. Consequently, people received care from staff who knew and understood them and with whom they felt comfortable. Staff were thoughtful and patient when providing care and supported people to make choices about all aspects of their daily life. Staff were respectful and showed empathy, compassion and kindness when speaking to people.

There were effective systems in place to ensure that people’s medication and personal information was kept safe.

The registered manager had a system for recording and analysing accidents and incidents, which enabled the service to learn from them.

Care plans were person centred and family members were consulted and involved in regular reviews. This ensured they were up to date and reflected people’s current needs. The registered manager had reviewed the process for assessing people before they moved into the service. This ensured staff were able to meet the needs of people.

People were supported to participate in a variety of activities.

Improvements had been made to the management of complaints. People and their relatives knew how to raise concerns or make a complaint and were confident the registered manager would take prompt and appropriate action to address any issues raised.

The provider had worked in conjunction with an external source and the local authority to embed changes within the service and meet breaches found during the previous inspection. The registered manager empowered staff and people to maximise their potential and achieve their goals. They had a clear vision for the service and systems were in place which enabled them to monitor and develop the service. Staff took pride in their work, felt valued by the provider and endorsed the values of the service.

The last comprehensive inspection of the service took place on 26 February 2015, at which time the service was rated as good. Following the receipt of information of concern relating to the safe care and treatment of people living at the service, person centred care, staffing levels and the management of the service a further responsive inspection took place on 21 December 2015. This inspection focused on the domains of safe and well-led and rated both areas as good.

We carried out the most recent inspection in response to concerns about the high number of safeguarding alerts raised by the service and problems highlighted by the local authority Quality Improvement and Organisational Safeguarding teams. The concerns were primarily in relation to the safe care and treatment of people using the service, insufficient staffing levels and ineffective leadership of the service.

The inspection took place across three days. The visits on 10 and 30 March 2017 were unannounced. The final inspection visit on 6 April 2017 was announced, during this visit we predominantly looked at the paperwork relating to staff files and the safety and maintenance of the service.

During the inspection we found that the provider was not meeting the legal requirements in multiple areas of the home. Following the first day of the inspection an urgent action letter was sent to the provider highlighting the concerns that we had found and requesting them to provide an action plan detailing the measures that they planned to implement in order to address these concerns. When we returned to the service for the second day of the inspection we found that the service had made some progress in addressing the concerns highlighted but continued improvements were required to ensure that people living in the service received safe, effective care from staff who had the necessary skills and knowledge to fulfil their roles.

On the first day of the inspection there was a registered manager in post at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. However, during the process of the inspection we were informed by the director of operations that the manager had resigned from their position and the service had appointed a new manager who was in the process of registering with the commission.

There were not enough suitably trained staff on all the units to ensure that people received safe care and support that was tailored to meet their individual needs. The service had failed to ensure that staff received appropriate training and support to help them develop the knowledge and skills needed to provide care which met the needs of people. This meant that the care provided did not consistently ensure that people were calm and settled and able to live full lives.

Across the service there was a heavy reliance upon agency nurses and care workers. This meant that people did not consistently receive care from staff who knew them well or who they knew and trusted.

The service had a system for monitoring accidents and incidents. However, not all staff had an understanding of what constituted an incident and therefore the correct process to report it had not been followed.

The service had a recruitment process in place to ensure that staff were safe to work with people living at the service.

The provider had not consistently worked in accordance with the principles of the Mental Capacity Act (2005) to protect people's rights. Physical intervention was being used routinely by staff when providing personal care to some people living at the service. This intervention was not documented in people’s care plans and was not being recorded or monitored to ascertain the frequency of its use or whether the level of intervention was appropriate and staff were not being supported in finding an alternative method to support the person.

The provider had not ensured that the overall service was caring as they had not taken action to ensure that people were safe or lived in an environment that promoted people's dignity. However, the individual staff who supported people were kind and caring and treated people with dignity and respect. Visiting times were flexible to enable people to have regular contact with their family and friends.

Care plans did not consistently reflect the needs of people. This meant that staff were not always aware of the risks associated with people's needs and lacked guidance on how to minimise potential risks. People did not always receive care and support that was suited to their individual needs and preferences. This meant that the care provided did not consistently support people to be calm and settled.

The provider had a complaints procedure, but historically verbal concerns raised by relatives had not always been addressed by the previous registered manager.

The management team did not have a clear oversight of the service and had failed to identify and respond to many of the issues raised during the inspection. There were systems in place to monitor the quality and safety of the service. However; they had not been used effectively and where shortfalls had been found appropriate action had not always been taken to resolve the issue.

Following the inspection the provider had devised an extensive action plan and was working towards improving the service and resolving the issues identified.

During this inspection we found several breaches of the Health and Social Care Act 2008. You can see what action we told the provider to take at the back of the full version of the report.

During our inspection we gathered evidence to help us answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well-led?

Below is a summary of what we found. The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

People told us that they felt safe in the home. One person said, 'I feel safe here. It's an excellent place to stay.' A relative we spoke with said: 'I feel (my relative) is safe here.' People told us that they felt their rights and dignity were respected and they felt in control of decisions about their care and support. There were systems in place to protect people from poor practices or abuse.

There were systems in place to ensure that managers and staff learnt from events such as accidents and incidents, complaints, whistleblowing and investigations. There was evidence of actions taken to address issues raised whenever this was needed. This helped to reduce the risks to people and encouraged the service to continually improve.

The service had made applications under the Deprivation of Liberty Safeguards (DoLs) in order to keep people safe. The clinical lead was in the process of reviewing all the people in the home who might need an application made under DoLs. This was to ensure that where a person lacked capacity, and an application had been authorised to deprive them of their liberty, any decisions were made in their best interests.

Is the service effective?

People told us that staff were effective in meeting their needs. One relative told us: 'Staff treat (my relative) as an individual and meet their individual needs.'

Is the service caring?

People were supported by respectful, supportive and attentive staff. People we spoke with were all complimentary about the staff and told us that they were 'very caring' 'helpful' and 'friendly'. Both the relatives we spoke with praised the staff. One of them said, 'The staff are friendly, calm and smiling. They are very caring. They seem to enjoy their job.' The other relative told us, 'Staff are respectful and caring.'

Is the service responsive?

People we spoke with told us that the staff were responsive to their requests and to changes in their needs. One person said: 'I ring the bell and they come running.' A relative described how staff responded extremely promptly to changes in people's medical condition. They told us, '(My relative) wasn't well over the weekend and they got the out of hours GP out. They communicate with me very well' A person living in the home said, 'If you're not well you can stay in bed. I go to bed when I want to.'

Is the service well led?

The levels of staff training and supervision needed to be improved, so that staff were supported to deliver care and services safely and effectively. Since the opening of the home in July 2013 the original manager had resigned in November 2013. The director of operations and a short term interim manager had also covered the home before the current manager was appointed in April 2014. The home had also used a number of bank and agency staff to fill vacancies. This had led to some variations in the management approach and on occasions difficulty in maintaining consistent standards. Agency staff usage had reduced considerably at the time of our inspection and continuity of care had now improved.

The service had a commitment to continuous quality improvement and an open culture. The service worked well with other agencies to ensure that people had continuity in their care. Staff, people and relatives appreciated that they now had stable management. A relative told us, 'Since the new manager took over the place has been running better.'

All the staff we spoke with told us that they enjoyed working at Foxburrow Grange. A member of staff said, 'The management is good. We're a good team. We have regular meetings and communication is good. We all support each other.' A relative described the management as 'open and understanding'. Another relative told us, 'They are very good at dealing with complaints. They have good systems in place.'