Fosse Court

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.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Care staff and the management team understood the importance of learning from incidents; for example, where people had periods of distress or injured themselves, changes were made to the care plan to reduce further risk. The registered manager said staff knew how to record incidents and how to escalate to them for investigation. Processes ensured any learning was communicated to staff through meetings, so they continued to have the right information to support people. One staff member told us, “Accidents and incidents are recorded using our standard accident forms and on the online system. Any safety concern is escalated to the management team straight away so that action can be taken promptly.”

People’s care records were updated if needed following an accident or incident. The registered manager reviewed accidents and incidents at the home and regular analysis identified any patterns or trends where actions could be taken. Where additional measures were needed to mitigate risks, this was considered and put in place when required. The provider told us they learnt lessons from inspections or audits undertaken within the service, whether positive or negative. They said it was important to share learning especially from external professionals, so they could continue to improve.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider supported people and their relatives to be fully involved when moving between services, completed comprehensive initial assessments including people’s histories and what mattered to them. This enabled staff to provide person led care and support. A person told us, “Before I moved here from [previous address] the manager came to visit me.”

The provider had safeguarding systems and processes to ensure compliance with statutory requirements and protect individuals from abuse and neglect. Comprehensive safeguarding records were maintained, documenting all incidents and the corresponding actions taken to mitigate future risks. These actions included notifying the local authority safeguarding team and updating the individual’s care plan in line with best practice. The registered manager conducted audits of these records to verify all safeguarding measures were implemented appropriately. Furthermore, the provider fulfilled its legal obligation to notify the Care Quality Commission (CQC) of any allegations of abuse in accordance with regulatory requirements.

Staff had completed safeguarding training and understood what to do if someone reported abuse. They knew how to report concerns about abuse or neglect and were supported by clear policies and procedures. Staff knew how they could raise concerns within the service and, if needed, with other organisations such as the local authority, the police, or CQC.

People can only have their freedom restricted for care and treatment if there is a legal process in place. In care homes, this is managed through the Deprivation of Liberty Safeguards (DoLS), part of the Mental Capacity Act 2005. The provider regularly checked and monitored these safeguards. Each person’s care plan included details about their capacity and any DoLS in place, explaining what this meant for their support. When people needed help to make decisions, staff recorded how choices were made in the person’s best interests.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and their relatives were involved in planning their care and assessing risks. Care plans were detailed and person-centred.

There were comprehensive risk assessments in place that were regularly reviewed and updated. These assessments enabled staff to understand people’s needs clearly and to deliver care in a safe and consistent manner. Care records were thorough and up to date, providing staff with the essential information required to deliver safe support.

A member of staff told us about how they access care plans and risk assessments,“I am given access to residents’ care plans and encouraged to read them during shifts. I have enough time to read and refer to them. This helps me understand how to support each person safely.”

The provider undertook comprehensive risk assessments of the premises and implemented measures to ensure the safety of people, staff, and visitors. Individual Personal Emergency Evacuation Plans (PEEPs) were in place for each person, detailing the specific procedures required to support their safe evacuation in the event of an emergency.

Fire alarm systems were subject to regular testing, and fire evacuation drills were conducted with the involvement of people using the service. The provider carried out a Legionella risk assessment and ensured that routine water testing was completed in accordance with health and safety requirements.

During the assessment, the lift was out of service; however, the registered manager confirmed repairs were scheduled to be completed within the coming weeks. No individuals using the service required the use of the lift and therefore were not adversely affected by this. Appropriate arrangements were in place to maintain safety and accessibility during this period.

Robust systems were in place to ensure the home and its equipment were properly maintained and serviced. Regular checks were carried out, including scheduled servicing and safety inspections such as electrical compliance testing and fire risk assessments.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People and relatives raised no concerns about staffing levels. Where people needed assistance, they received this with minimal delay. The registered manager told us they assessed the staffing levels needed to meet the needs of all the people who used the service. One staff member said, “In general, staffing levels are maintained well, and the rota is organised in a way that ensures residents’ needs are met. When there are shortages, we arrange cover to keep the service and service users safe.”

The provider undertook appropriate recruitment checks before staff stated working at the service to ensure the suitability of staff before they commenced employment. These included obtaining references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This helps providers make safe recruitment decisions.

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.

The home and equipment were clean, and risks associated with infections were assessed and well managed. There were regular checks and audits of cleanliness and hygiene. Staff had received training in infection prevention and control.

People told us their home was kept clean. One person said, “My personal room has a single bed, wardrobe and set of drawers, I have a wash basin in my room, it is not ensuite. I have laminate on my bedroom floor. I do use the communal showers and toilet which are kept clean.”

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.

Medicine management systems were well organised and ensured people received their medicines as prescribed. People who were prescribed medicines on an as and when required basis, had protocols in place to ensure safe administration. Staff responsible for administering medicines received training and had their competencies checked to ensure they could administer medicines safely.

People told us they were happy with how their medicines were managed. One person told us, “I get support with my medication every day. I take many tablets, and I like to take them with water. I prefer to take them one by one.”