Fox Elms Care Limited

About the service

Fox Elms Care Ltd is a domiciliary care service providing personal care to those with a learning disability or complex needs in their own homes or a supported living setting.

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

The service was partially able to demonstrate how they were meeting the underpinning principles of ‘Right support, right care, right culture’.

Right Support

People had a choice about their living environment and were able to personalise their rooms. People could access specialist health and social care support in the community. The provider was working to improve and develop the relationships with healthcare professionals and the local authority.

Right Care

The service did not always ensure that risks faced by people in relation to medicines, epilepsy and infection control had been consistently identified, assessed and planned for. The provider was working to ensure the records relating to the management of people’s care were up-to-date and reflective of their needs.

Right Culture

The provider had not had consistent oversight of the service since our last inspection. There had been a delay in implementing an effective quality assurance system which meant that records were inconsistent and the culture at the service was not always positive. Prior to our inspection a new senior management team had implemented a service improvement plan. They had made considerable progress, although more time was needed to fully implement and embed the necessary improvements.

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

Why we inspected

This inspection was prompted in part by the provider's notification to CQC of a significant event. The information shared with CQC about the incident indicated potential concerns about safe care and treatment. We also undertook this inspection to assess that the service is applying the principles of Right support right care right culture.

Enforcement and Recommendations

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 a breach in relation to Regulation 17 (Good governance).

We have made a recommendation about the management of some medicines.

Please see the action we have told the provider to take at the end of this 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Fox Elms Care Ltd was acquired by Voyage Care on 2nd July 2019, and is a domiciliary care service providing personal care to those with a learning disability or complex needs in their own homes or a supported living setting.

CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. At the time of our inspection 56 people were receiving personal care.

The service was managed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence.

People's opportunities to follow their goals and live as full a life as possible had been impacted by COVID-19. The service had reviewed restrictions on people's activities and movements in line with national guidance and additional internal activities had been set up to ensure people were protected from feelings of isolation.

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

Some improvement was needed in record and incident monitoring to achieve greater safety and consistency, and have made recommendations regarding the review of people's care and support plans and the providers safety incident reporting process.

Processes and systems had been introduced to help better monitor the quality of services provided, however, we found that people’s support plans and risk assessments had not always been reviewed to reflect people’s current needs and levels of risk. More time was needed to ensure that the systems introduced would be effective in driving improvement to the service and whether these would be sustained.

People receiving care told us they felt safe and that they would report any concerns to a member of staff. Staff were knowledgeable about local safeguarding procedures and knew how to raise safeguarding concerns. However, the provider informed us during our inspection that there had been three safety incidents that had not been reported appropriately. The provider told us they were taking immediate action to investigate this to reduce the risk of this reoccurring and would report these safety incidents to the relevant agencies without further delay.

Staff had received training and support, and the service had various methods of communicating with staff in order to keep them updated and informed. Staff had mixed views on the culture of the home, indicating that they did not always feel valued. However, one newer member of staff told us they had felt very well supported by the provider and its leaders and told us they would definitely recommend Voyage care as an organisation to work for.

Staff responsible for administering people’s prescribed medicines had received training and competency assessments. During our inspection we found that people had received their medicines as prescribed. The provider was investigating and taking action to address recent medicine administration errors.

People had access to healthcare professionals and staff communicated effectively with these professionals to aid consistent care.

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

Rating at last inspection

At the last inspection in February 2019 the service was rated as good (report published 2 April 2019).

Why we inspected

A focused inspection was completed due to concerns received about medicines management and the quality of people’s care. A decision was made for us to inspect and examine these concerns.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Fox Elms Care Limited provides personal care to people with a learning disability, mental health or acquired brain injury living in their own homes or supported living in Gloucestershire.

People’s experience of using this service:

• The staff told us about the issues with the landlord and told us that some tenancy agreements were not adhered. We noted that external environments were not well maintained and where housekeeping was the responsibility of the landlord this was not happening. We recommend that the registered manager seek guidance from a reputable source or inform commissioners of placements that landlords were not adhering to their contracts.

• Staff that administered medicines had attended appropriate training. Medicine administration records were signed to indicate medicines administered. Some MAR did not include the medicines received. Where medicines were discontinued or duplicated it was not made clear in the MAR.

• Quality assurance systems were in place. Where shortfalls were identified action was taken to improve the quality of service delivery. Incident and accidents were reported and analysed for patterns and trends.

• We received feedback through questionnaires about the agency which we followed up during the inspection. Questionnaires were sent to people, relatives, staff and community professional before the inspection. The registered manager said that at the time morale was low due to changes in staff rotas and registration changes. The relatives and staff we spoke with during the inspection gave positive feedback about the care and treatment people received.

• New staff said they had an induction to prepare them for their role. They said their induction included shadowing more experienced staff.

• The training matrix confirmed staff attended training set as mandatory. Staff told us mandatory training was online at the agency office where the trainer was available for support.

• We saw copies of one to one supervision meetings which confirmed regular supervision. However, some staff said they had not had regular one to one supervision meetings.

• Staffing levels were maintained by agency staff. Staff told us there was enough time

allocated to deliver personal care and was not rushed. Most people living in supported living locations were having one to one support from staff.

• Recruitment procedures were in place and administrative staff were currently ensuring staff files were up to date. The registered manager told us action was being taken to recruit permanent staff.

• Care plans were mostly person centred. People’s life stories were introduced. Guidance from community professionals was part of the care plans. Individual risks to people included falls, choking and behaviours people used to express anxiety and frustration. Risks were assessed and action plans were developed on how to minimise the risk.

• Staff knew the day to day decisions people were able to make and Deprivation of Liberty Safeguards (DoLS) were made for people subject to continuous supervision.

• Where necessary staff made GP appointments. Staff said they were kept informed about visits from healthcare professionals.

• Complaints received were investigated and lessons were learnt from these events.

• The staff we spoke with told us how they ensured that people were made to feel they mattered. These staff explained the importance of developing relationships with people.

Rating at last inspection:

The service was rated as good at the comprehensive inspection dated 29 February 2016. The home retained the good rating in Safe at the focus inspection dated 10 January 2017.

Why we inspected:

This inspection was a scheduled inspection based on previous rating.

Follow up:

We will monitor all intelligence we receive about the service to inform when the next inspection should take place.

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

At the last inspection on 3 February 2016, the service was rated Good.

This focussed unannounced inspection on 16 December 2016 was prompted in part by a notification of an incident following which a person using the service died. This incident is subject to a coroner investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of the risk of choking. This inspection examined those risks and other risks people might potentially face.

There was a registered manager in place. 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.

At this inspection we found the service remained Good.

People’s care and support considered risks to their safety and systems had been put in place to manage these. Accident and incident records monitored events and action had been taken to respond to these involving the input and advice of health care professionals. People were supported by staff who understood how to respond in an emergency to any accidents, incidents or near misses.

Further information is in the detailed findings below.

There was a registered manager in post. 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 and associated Regulations about how the service is run.

People received personalised care and support which reflected their assessed needs. Their care records identified their preferences, routines and aspirations. Step by step guidance was provided for staff about how people wished to be supported with their personal care. People’s levels of independence were clearly identified. People’s diversity was acknowledged and if their age, disability or religion impacted on their care this was respected. People’s human rights were upheld and staff helped them to stay safe from harm or injury. Staff understood people really well and knew how to support them when they were anxious or distressed. People were respected and treated with dignity. They had positive relationships with staff and were confident in their company. People’s capacity to consent to aspects of their care and support were considered and if needed decisions were made in their best interests. People made choices about their day to day lives and directed staff about how they wished to spend their time. A person told us, “I cannot rate too highly the care and support I receive from Fox Elms. It is excellent and totally reliable.”

People were supported by staff who had been through a recruitment process. People met with new staff informally at their homes and some had been involved in the interview process. Small changes were made to the recruitment process during the inspection, to make sure it was robust. Staff had the opportunity to acquire the skills and knowledge they needed to carry out their roles. They said they felt supported in their roles and would raise any concerns or issues with the registered manager. Individual and team meetings provided the chance for staff to reflect on their roles, training needs and the care they provided. Out of hours management support was provided in case this was needed in an emergency. There were enough staff to meet people’s individual needs. People had copies of staff schedules so they knew who was supporting them and at what time.

People, their relatives and staff had been asked for their views about Fox Elms and their experiences of the care they received. This was done formally each year in a survey, as well as during reviews of their care and through the monitoring of complaints and compliments. A range of quality assurance systems and external audits by the local authority were used to monitor and improve the care and support provided. The vision for the service to, “offer every person that we support a service that is truly centred on their own needs, abilities and desires” was endorsed by staff in their day to day work. A relative commented, “Gloucestershire in our opinion is very fortunate to have such an agency”.

As part of this inspection we spoke with seven people who use the service, observed 11 people being supported, spoke with the registered manager and 14 care staff. We also reviewed records relating to the management of the service which included 10 care plans, daily care records, safeguarding systems, staff information and quality assurance audits.

We used a number of different methods to help us understand the experiences of people using the service because they had complex needs which meant they were not all able to tell us their experiences. We spoke with other social and health care professionals involved in their care.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

Is the service safe?

People were kept safe because when people displayed behaviour which challenged others staff dealt with it safely and respected people's dignity and protected their rights. Staff had a good understanding of the strategies in place to support people when anxious, upset or frustrated. When people were at risk, staff followed their care plans, risk assessments and behaviour guidance to protect them.

People were safe because the service had a system to manage accidents and incidents and learn from them so they were less likely to happen again. We found audits of accidents and incidents were analysed and action had been taken to prevent them from happening again. A person told us, "I feel safe living here".

People were safe because staffing levels were assessed and monitored to ensure they were sufficient to meet their identified needs. The provider considered the skill mix, competencies, knowledge, qualifications and experience of staff when arranging staffing that would meet people's individual needs. People told us, "Staff are ok."

Is the service effective?

People received an effective service because they were supported to be involved in the assessment of their needs and had a choice about who provided their personal care. Where people had preferences about the gender of staff who provided their care this was recorded in their care plans and respected by the provider when staff were allocated.

The service was effective because people's individual needs, choices and preferences were reflected in their care plans. People's likes, dislikes and routines important to them were identified. We saw their care plans reflected these and provided staff with clear information about the way they wished to be supported.

People received an effective service because referrals were quickly made to health services when their needs changed. People's routine health needs and preferences were met by a range of social and health professionals helping them to stay healthy.

Is the service caring?

People received a service which was caring because they were treated with kindness, compassion and dignity in their day to day care. Staff knew the people they were caring for and supporting, including their preferences and personal histories. Staff showed concern for people's wellbeing. We observed staff supporting people with confidence, shared humour and sensitivity. People told us, "I have a laugh with staff, I have no problems with them." We observed positive interactions between staff and people using the service. A member of staff told us, 'We look at how the individual sees the world and start from there with our support.'

Is the service responsive?

People received a responsive service because they received care, treatment and support when they needed it. People were asked about what was important to them. People's individual needs were regularly reassessed and any changes in their care were reflected in their care plans and risk assessments.

The service was responsive because people, their relatives and staff were encouraged to provide feedback. As part of the quality assurance process people told the provider, "personalised care packages", "(you) create a calm environment for clients".

Is the service well led?

The service was well led because staff knew and understood what was expected of them. Staff spoke with confidence about how they supported people and about the provider's policies and procedures.

Robust quality assurance and governance systems were in place and were used to drive improvements across the service. These evidenced continuing improvements within the service. The quality assurance plan for 2014 identified actions to improve the service such as improvements to the induction programme for new staff and changes to the way the provider communicated with staff by increasing individual or team meetings.

The service was well led because they worked in partnership with key organisations, including the other agencies and safeguarding teams, to support care provision and service development. Audits by other social care professionals had led to improvements in the quality of care records maintained for people.