CQC report explained · a nursing home
What the CQC found at Foxleigh Grove Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2020
Foxleigh Grove Nursing Home was rated Requires Improvement; inspectors found kind, responsive care but weaknesses in medicines, assessments and quality checks.
This was an unannounced inspection on 14 January 2020. Inspectors spoke with people, relatives and staff, observed meals and medicines, and checked care records, medicine records, staff files and management records.
People generally felt safe and praised the staff's kindness. The home was clean and homely. People received suitable food, activities and support to maintain relationships. Staff respected people's choices, privacy and dignity.
Inspectors found important gaps. Some medicines guidance and staff competency checks were missing. A person who fell and showed signs of pain did not receive medical attention until two days later and was found to have a fracture. Some respite residents did not have complete assessments or care plans.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive remained Good. The provider was required to send an action plan, and CQC said it would monitor progress and return.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors observed calm, kind interactions and saw people treated with dignity and encouraged to make choices.
“We observed kind interactions between people and staff throughout the day.” from the report
Clean and homely setting
The home was described as warm, calm and homely. Inspectors found it clean and free from unpleasant smells, with suitable infection control practices.
“The service was clean and free of malodours.” from the report
Activities and relationships
People had a varied activities programme and were supported to maintain hobbies and contact with family and friends.
“People were supported to maintain their hobbies and interests.” from the report
Choice and privacy
Staff asked people for consent and offered everyday choices. Personal care was provided in a way that protected privacy and dignity.
“People were regularly offered choices, such as where they would like to sit, and those choices were always respected.” from the report
Medicines checks and instructions
seriousStaff did not always have their medicine knowledge and competence checked as recommended. There was also no guidance for staff on when to give some as-required medicines.
“Where people were prescribed 'as required' (PRN) medicines, guidance was not in place to support staff on when to administer these medicines.” from the report
Delayed response after a fall
seriousA person showed signs of pain after a fall, but medical attention was not sought for two days. The person was later found to have a fracture.
“This person was indicating pain and medical attention was not sought until two days after the person was displaying signs of pain.” from the report
Incomplete respite assessments
needs fixingSome people staying temporarily for respite did not have complete assessments or care plans to guide staff about their needs and preferences.
“There were no care plans in place to provide guidance to staff on these people's preferences and how they would like their care to be delivered.” from the report
Weak quality monitoring
seriousAudits were not always completed regularly or effective enough to identify problems. Incident records also had gaps and did not always show what lessons had been learned.
“However, we found that these had not always been completed regularly and had not always identified weaknesses highlighted during the inspection.” from the report
Recruitment records
needs fixingSome staff files did not contain full employment histories or evidence of satisfactory conduct checks. In one case, the adult barred list had not been checked.
“The provider had not recorded that they had assessed the risk of employing someone without this evidence.” from the report
- 01What action has been taken to ensure every staff member who gives medicines has regular knowledge and competency checks?
- 02What written guidance is now available for each person's as-required medicine, and how is staff understanding checked?
- 03What is the home's falls pathway, and how will staff ensure people showing pain after a fall receive prompt medical attention?
- 04How are complete assessments and care plans prepared for people admitted for respite care?
- 05Which audits now check medicines, care plans, incidents and emergency evacuation plans, and how are resulting actions followed up?
This was an unannounced planned inspection covering all five key questions; the previous Good ratings had changed to Requires Improvement for Safe, Effective and Well-led, while Caring and Responsive remained Good. This explanation was written from the published report of 7 March 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2017
Foxleigh Grove Nursing Home was rated Good; inspectors found kind, safer care, but identified improvements needed to records, participation and the building.
The inspection was unannounced and took place on 10 July 2017. Inspectors observed care, spoke with people, relatives and staff, and checked medicines, care records, staff files and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines management, improved staff training, better support with nutrition and lawful decision-making when people could not consent.
People and relatives described staff as kind and respectful. Care was personalised, activities were available and healthcare support was arranged. However, inspectors recommended further work on internal refurbishment, involving people in care decisions, access to conditions on liberty safeguards, feedback and complaints processes.
Kind and respectful care
People and relatives reported that staff were kind and caring. Inspectors observed staff being friendly, patient and respectful, and protecting people's privacy.
“People and others told us staff were kind and caring.” from the report
Improved safety
The home had acted on earlier concerns about medicines and other safety issues. Inspectors found safer medicine systems, risk assessments and sufficient staffing.
“The service took steps to improve and sustain the safe management of people's medicines.” from the report
Food and nutrition
People had meal choices and received help when needed. Risks of weight loss were identified and managed with food supplements, professional referrals and extra encouragement.
“People were supported to maintain a healthy, balanced diet.” from the report
Personalised care and activities
Care plans covered individual needs and preferences. People could join group activities or receive activities in their rooms, with regular trips into the community.
“People's care was personalised.” from the report
Positive management and teamwork
Inspectors found regular checks on care quality and good communication between staff. Staff showed a positive workplace spirit and worked together to respond to people's changing needs.
“There was a good team culture amongst staff that provided care.” from the report
Building and infection control
needs fixingSome bathrooms, showers, hallways and sluice rooms had surfaces that were becoming harder to keep clean. Further refurbishment was recommended to reduce infection control risks.
“We noted some areas of the building required further improvement to ensure that effective infection prevention and control can continue to occur.” from the report
Involvement in care decisions
needs fixingThe inspection could not clearly show that people were involved in planning and reviewing their care because records were mainly completed on computers in staff-only areas.
“The inclusion of people in their care planning and review was difficult to evidence.” from the report
Some records were inaccurate
needs fixingTwo electronic care plans did not accurately record the frequency of falls. Some other computer-based information did not match the care people received.
“The falls risk assessment showed high risks, however the information about the frequency of the falls was not accurate.” from the report
Complaints information and records
minorThe home had a complaints process, but there was no clear poster in communal areas and the one complaint reviewed did not have a fully robust investigation record.
“Further signage and documentation was required to point out the complaints process.” from the report
Training was not fully up to date
minorStaff training had improved, but some staff had not completed all mandatory training topics at the time of inspection.
“There continued to be areas for improvement in staff training, as not all staff were up-to-date with all the mandatory topics.” from the report
- 01What work has been completed on the bathrooms, showers, hallways and sluice rooms since the inspection?
- 02How do you involve residents and relatives in care planning and reviews now?
- 03How do you make sure electronic care records accurately reflect falls and other changing risks?
- 04How can residents and relatives make a complaint, and how are investigations and outcomes recorded?
- 05How do you check that all staff have completed their mandatory training and medicines competency assessments?
This was an unannounced comprehensive inspection covering all five CQC questions and checking whether improvements required at the previous inspection had been completed. This explanation was written from the published report of 27 July 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Foxleigh Grove Nursing Home
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- March 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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