Foxleigh Grove Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question requires improvement. The provider was previously in breach of the legal regulation in relation to governance. Enough improvements were found at this assessment and the provider was no longer in breach of this regulation. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.
 

This service scored 61 (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 did not always have a clear shared vision, strategy and culture.

The provider did not always enable communication with relatives to ensure they were able discuss any matters or what was going on in the service. Relatives told us they did not always find it easy to engage with leaders. One relative said, “I feel the managers could be more visible and available to visiting relatives so they feel they can easily raise small things in passing as opposed to having to phone.” Relatives also told us they were not formally invited to reviews, and the provider could be more proactive about this process. However, they felt able to engage with the service when needed.

Staff told us some leaders were more “hands on” than others. Staff also told us they were not all involved in people’s care planning. However, they communicated any changes to relevant staff who were able to make changes. Although staff could not clearly explain what the values of the service were , we observed they interacted well with people and relatives throughout our visit. One staff told us, “The value of the service should be high. The value is good. I will give you an example. It should be good care. We should give good care to people.”
 

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us they felt leadership supported them to resolve any issues quickly. One said, “When I report something it is done. Sometimes there is a communication problem, but that can be sorted easily. They talk very nice with us. [Provider] is brilliant.”
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us, “If I saw anything, anything I didn’t feel was right, I would feel free to go to the management or the nurse in charge or outside agencies. Their doors are always open.” People also told us they felt comfortable speaking to the provider with any concerns, and they felt these were responded to.
 

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We received mixed feedback from staff about inclusion and diversity. One said, “Sometimes there is a bit of racism, I feel it is not [leaders]. I feel like it’s staff.” However, other staff told us, “We go out for people’s birthday, I think it is a good team spirit. There are different nationalities and it is very good.”

The provider told us, “We have a very diverse workforce. There are no barriers to anyone being able to work here. We respect people’s religious and cultural needs. We have constant open dialogue. Some training is available in other languages.” However, this meant provider needed to make some improvements to ensure there was a consistency in how staff felt about inclusivity within the workforce.
 

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

Internal governance procedures were generally in place with a range of quality monitoring systems and audits. These had helped identify where actions were required and areas for improvement. However, we identified some areas in which the provider did not demonstrate they always maintained effective oversight and governance. For example, we found some medicines were left unattended in the corridor with people’s identifiable information. We informed the provider about this and they took immediate action. The provider completed audits as part of medicines management.

Provider needed to improve the oversight of training and competencies, and staff recruitment records to ensure people were not at risk of being support by unsuitable or unqualified staff.
The provider did not always ensure maintenance governance processes were clear. The provider did not always ensure records were easily accessible to support effective oversight of what was in place. However, the service had a clear audit schedule, and regular governance meetings took place. There were clear safeguarding and incident reporting processes in place to ensure these were tracked, monitored and learnt from.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We received positive feedback from partnership agencies. For example, one said, “Recent safeguarding showed engagement and proactive approach to any outcomes by the manager.” Another said, “Communication between the [services] is consistently timely, clear, and well-coordinated. The team promptly notifies us of medication changes, clearly highlighting urgency when required, which ensures that resident safety is maintained and continuity of care is not compromised.”

People also told us they were supported to access external services such as the GP and dentist when required.
 

The provider did not always focus on continuous learning and improvement across the service.

They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. For example, the provider told us they had received some previous recommendations to introduce signage within the home to support orientation for people with dementia, they had not demonstrated they implemented these adaptations.

The provider held regular staff meetings. We found these were detailed and explored themes including falls data, current guidance for COVID, care planning, end of life discussions and contacting GP for antibiotics. The provider also demonstrated new monitoring tools they had established as a basis for quarterly oversight discussions. This tool included collating data for themes such as falls, types of clinical infections and reasons for hospital admissions.