Foxby Hill Care 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 Good. At this assessment the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to consent, safe care and treatment, and safeguarding people from abuse and improper treatment.

This service scored 50 (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 proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider did not have effective systems in place to ensure responsive learning from incidents, and feedback from a health care professional indicated the provider was not always responsive to risk. Falls incidents were not always well managed to prevent reoccurrence. Consequently, there was a high frequency of falls at the service, exposing people to prolonged risk of potential harm. Some staff were not aware of recent incidents that had taken place at the service. One staff member told us, “There have been no accidents or incidents.” Another staff member said, “There have been no accidents or incidents since I joined.” This indicated a lack of communication and information sharing to ensure effective learning from incidents.”

People and their relatives were mostly satisfied with the care they received and felt the provider was responsive. One relative told us, “They [staff] are very good if there are any issues they [staff] ring me.”

The provider worked well with people and healthcare partners to support care transitions. However, they did not always make sure there was continuity of care.

The provider worked well with people and healthcare partners to support smooth transitions of care. A relative told us, “It was a very smooth transition from hospital. I was a little cross the hospital discharged [relative] in pyjamas, but the care home sorted [relative] out when they got here.” However, systems of care were not always effective at ensuring guidance for staff about people's health conditions was accurate and update to date.

People’s essential information and records were available to support people with emergencies and hospital transitions. These included people’s Recommended Summary Plan for Emergency Care (ReSPECT), people’s Personalised Emergency Evacuation Plans (PEEPs), and people’s hospital passports. These documents supported external health professionals and care staff at the service to understand people’s essential needs and wishes.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

An effective procedure was in place for recording and reporting safeguarding incidents. Staff were trained in safeguarding and understood how and when to report concerns. The provider maintained oversight of safeguarding concerns. However, the provider identified a potential concern that had not been reported by a previous manager. They responded promptly and took appropriate action to report the concerns and involve the appropriate authorities.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The provider did not always follow the principles of the MCA and systems to track and monitor DoLs authorisation were not always effective. People’s freedom was sometimes restricted to ensure their safety. However, the necessary assessments were not always in place to ensure that least restrictive options had been considered.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were put at risk of choking. A staff member was observed supporting people with their meals whilst lying down in bed, with the bed set only to a slight incline. We raised this with the provider who took immediate action to address the unsafe staff conduct.

A person was not fully protected from the risk of potential burns. There was no consideration in their care plans or risk assessments regarding the associated risk with smoking following the administration of flammable paraffin-based emollient creams to their skin.

People were not always fully protected from risks related to skin pressure areas. A person was not always repositioned within the time specified in their care plan, and another person’s pressure mattress was not set to the correct pressure.

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.

A person was exposed to increased risk of developing a skin tear or related injury due to a screw protruding out of a chest of drawers in their bedroom. We raised with the maintenance staff on site who removed the screw. Freestanding wardrobes exposed people to potential risk of harm in the event they should fall and there was no related risk management procedure in place. Feedback from people and their relatives indicated they did not always feel the environment was appropriate for people. One relative said, “[Relative’s] room looks a bit dilapidated and doesn’t feel homely.”

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. They did not always work together well to provide safe care that met people’s individual needs.

We observed people were supported by enough staff. The provider used a dependency tool and staffing rotas to ensure there were suitable numbers of staff available each day. However, people and their relatives did not feel there were sufficient staff. One person told us, “There are never enough staff anywhere.” Another person said, “Staff are always in a hurry, they never stop and talk to me.” One relative told us, “Sometimes they seem to be short staffed. The number of staff on the ground seems low at times and I notice some residents having to wait for the toilet.” The provider had not ensured the views of people had been taken into consideration when allocating and deploying staff, resulting in people not always receiving the care they needed in a timely manner. At times we observed a lack of leadership oversight during daily service delivery. This meant leaders could not always be assured care was delivered in a safe appropriate manner.

Staff received training relevant to people’s needs. Competency assessments were in place to ensure staff were skilled to deliver particular tasks such as administering medicines. However, not all staff displayed consistent competence to ensure safe care delivery. For example, supporting people with their meals safely, or ensuring effective communication about advice from health professionals.

Saferrecruitment checks were completed to ensure staff were suitable and had the necessary experience and skills for their role.

The provider mostly assessed and managed the risk of infection. However, improvements were required to ensure consistency.

The service was mostly clean and tidy throughout. However, some floors and surfaces were found to be sticky. This indicated surfaces had not been properly sanitised to prevent the risk of the spread of infectious bacteria. Porous surfaces were exposed in a washroom facility. This presented an increased risk of buildup of bacteria. Some mattresses and mattress covers in people’s bedrooms were found to be stained and with mall odour.

Staff used personal protective equipment when supporting people with personal care and other tasks. Hand wash facilities and antibacterial hand sanitiser were available throughout the service. Staff receive training in relation to infection prevention and control.

The provider did not always make sure that medicines and treatments were managed safely. The provider did not always ensure medicines were planned effectively.

Medicine stock checks were not effective at identifying discrepancies in a timely manner. This meant the provider failed to ensure people’s safety when receiving their daily prescribed medicines. People’s care plans did not always contain sufficient detail to ensure staff had access to suitable guidance on how to manage time critical medicines.

Administration records were well maintained and staff supporting people with their daily medicines had suitable knowledge on their needs and personal preferences. Feedback from people and their relatives indicated they felt medicines were managed safely.