Foxleigh Grove 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 question requires improvement. The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment and the provider was no longer in breach of this regulation. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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.

The registered manager told us they completed root cause analyses and reviewed accident forms weekly to identify patterns and trends. They also said, “Sometimes they are spoken about during staff handovers…We approach it with transparency, we speak to residents and staff and identify any areas where we could have done better.”

The provider had completed and maintained detailed incident reporting forms. We discussed with them how this could be strengthened by including additional details of any follow up actions taken, including what input visiting healthcare professionals had.

Relatives told us they were kept informed when incidents occurred, including action taken and referrals made to external agencies.
 

The provider did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They did not always make sure there was continuity of care, including when people moved between different services.

When people were discharged from hospital, they did not always have detailed care records in place or the appropriate equipment to support a smooth transition. One person told us there had been some concerns regarding equipment needed for them and communication with them when they moved into the service.

Another person who had recently moved into the service was insulin dependent, we found a full risk assessment and care plan had not been completed to direct staff in how to support their needs. Although some core information was noted on their care record, there were discrepancies on staff handover sheets. For example, the handover sheet did not mention the person was insulin dependent, and despite detailing other information about their needs. The provider informed us they aimed to ensure people had good experience transferring between service.However, this person’s feedback noted some improvements to the admission experience were still needed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.
We saw the provider maintained effective monitoring logs to ensure incidents and accidents were safeguarded without delay.

The provider told us they had a good working relationship with the safeguarding team, and displayed posters for staff in the clinical room with information about how to contact safeguarding.
The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty.
 

The provider did not always work well with people to understand and manage risks.

Staff understood people’s needs and acted safely in practice; however, we found care records and risk reviews did not always reflect this. Some information was not always detailed to safely guide staff when delivering care and treatment. For example, one person’s care plan did not contain information about which signs staff should look out for when monitoring the catheter site. Another person required 4 hourly repositioning, and this was not always recorded. We found several gaps in recording support to reposition the person to prevent deterioration of their skin.

We found personal evacuation plans were up to date, ensuring people could be supported safely in an emergency.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We reviewed supporting documentation with regards to the environment. The provider’s fire risk assessment policy stated the fire risk assessments should be reviewed twice a year. However, we found this was only reviewed once a year. This meant the provider did not follow their established safety steps to ensure they reviewed for any fire risks in the service.

The provider used an external service to complete legionella risk assessments, gas safety and lift servicing. The provider made sure fire drills were completed, and records maintained for action notes with identified learning from these events.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff training and competency assessments were generally in place. However, the provider did not demonstrate how they ensured all competency assessors were competent to assess other staff for various tasks such as medicines administration and catheter care. The provider could not demonstrate recent competencies were in place for tasks such as emergency rescue medicines administration and catheter care at the time of the visit but told us these training sessions were scheduled to be completed.

The provider completed most pre-employment checks. However, we found they had not always assured they had evidenced these in line with their recruitment policy.The provider’s training matrix demonstrated staff completed learning across several topics and modules.
 

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.

We saw the provider completed 3 monthly audits for infection, prevention and control (IPC). There were identified outcomes from these audits which were reflected in the staff training matrix, which demonstrated not all staff had completed training in this area. We observed staff preparing food wore the appropriate personal protective equipment.

The registered manager told us how they managed the risk of infection. They said, “We have hand hygiene audits and monitoring observations with staff. We have an IPC champion . We have a weekly cleaning list in the treatment room which the nurses need to do. The carers have a list for night-time for thorough cleaning of equipment. We keep up to date with policies. In touch with ICB, we get alerts what is prevalent in the area e.g. Norovirus. We seek consent and make sure residents are up to date with their vaccines.”
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

We found most people had clear identifiable information, details of how they like to take their medicines, and known allergies on the front of their medicines administration records (MAR). Where ‘as needed’ (PRN) medicines were in place, the provider maintained clear protocols for staff to administer these safely and effectively. Where topical medicines were administered, we found clear records were maintained to manage this. Topical medications are creams, ointments, gels, or liquids. We found timed medicines were administered correctly.