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Inspection carried out on 21 February 2019

During a routine inspection

About the service:

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

Inspection carried out on 16 December 2016

During an inspection to make sure that the improvements required had been made

Fox Elms Care provides personal care to older and younger people with a learning disability, sensory or physical disability or mental health needs living in their own homes in Gloucestershire. Some people lived in private homes on their own or with family and other people lived in shared housing. Fox Elms Care was providing personal care to 25 people at the time of our inspection.

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.

Inspection carried out on 3 February 2016

During a routine inspection

This inspection took place on 3 and 8 February 2016 and was unannounced. Fox Elms Care provides personal care to older and younger people with a learning disability, sensory or physical disability or mental health needs living in their own homes in Gloucestershire. Some people lived in private homes on their own or with family and other people lived in shared housing. Fox Elms Care was providing personal care to 26 people at the time of our inspection.

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”.

Inspection carried out on 11, 12, 13 June 2014

During a routine inspection

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

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.