Foxby Hill Care 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 Good. At this assessment the rating has changed to 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. The service was in breach of legal regulation in relation to governance at the service.

This service scored 43 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff mostly described a positive workplace culture, but some staff stated the lack of consistent leadership made things difficult. The provider was aware service development was required, and feedback from staff indicated things were improving, but they also told us further development was needed. One staff member summarised the situation by saying, “It will be better when there’s a manager in place and settled.”

There was a lack of consistency across the service. For example, the mealtime experience in the Bluebell unit was notable less personalised and engaged compared with the experience of people in Warren Lodge.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

At the time of this assessment there was no registered manager in post at the service. Whilst the provider had taken appropriate steps to recruit an appropriate person for the role of registered manager, the service had suffered from a number of managers leaving the service after only a short time in post. During this turbulent period the service was led by the quality compliance manager, whom we found to be competent and dedicated. However, they explained it had been difficult to provide continuity of leadership as a result of managers coming and going at the service. This negatively impacted leadership and oversight at the service.

Feedback from some staff, relatives and professionals indicated leaders at the service did not always act with integrity. For example, a relative told us the provider had recently changed the time of lunch service from 12:00 to 13:00. They said, “We are unhappy there was no consultation with people or their relatives on this change. It made [relative] agitated as they are hungry by 12:00 noon and is often looking for their lunch to arrive.”

Most felt they could speak up and their voice would be heard. However, some people and their relatives did not know who they could speak to. One relative told us, “We don’t know who to speak to, we are not aware of any manager.”

Feedback from staff was varied. Some staff felt able to raise concerns, others did not. Some staff were not familiar with the service’s freedom to speak up or whistleblowing procedures. One staff member told us they were instructed by leaders at the service not to raise any negative feedback as part of this assessment. This indicated a negative closed culture at the service.

The provider mostly valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. However, the lack of consistent leadership impacted staff morale.

Staff felt they were treated equally by leaders at the service. They told us there was a suitable staff room and they received regular breaks. However, some staff described how the lack of consistent leadership impacted morale. One staff member told us, “No management consistency at the moment, in limbo and morale is low.”

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Quality assurance processes were not effective. For example, quality audits had not identified environmental hazards, medicine stock discrepancies or missing information in people’s care plans and risk assessment documents. This meant opportunities to identify risk were missed and people were exposed to prolonged risk of potential harm or poor care.

There was a lack of oversight of daily operations at the service which exposed people to avoidable risk of potential harm. For example, leaders at the service did not have oversight of how people were being supported with their meals, and we observed a staff member put people at increased risk of choking through unsafe practice. There was also no awareness that people did not always have access to drinks throughout the day. This lack of oversight meant the provider failed to ensure people received safe and appropriate care.

The provider did not understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Feedback from a health and social care professional indicated the service was not forthcoming with identifying and escalating concerns of people’s deteriorating health and was resistant to working with other services to improve people’s care. They described attempts to work with leaders at the service to better support people to reduce their frequency and risk of falls, but said leaders were not proactive at implementing advice or engaging with the support offered. This meant opportunities to work in partnership to improve the care people received were missed, and people were exposed to prolonged risk of potential harm.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had developed a number of oversight systems designed at focusing on continuous learning and service improvement. However, these were not always effective. For example, a service improvement plan was in place that recorded ongoing improvements were needed in relation to people’s mental capacity assessments (MCA). However, a full audit of MCA’s had not been completed to fully understand the scale of the task required and to ensure these were completed to a high standard and in a timely manner. We found significant shortfalls with MCA’s and no clear plan as to how the provider intended to become compliant.