The inspection was unannounced and took place on 7 and 15 December 2017. Foxburrow Grange is registered to provide accommodation and nursing care for up to 66 older people. The service is split into four units, each of which has separate adapted facilities. On the day of the inspection there were 59 people living at the service.

At our last inspection on 10 March 2017, we found the provider to be in breach of multiple regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found incomplete risk assessments and a lack of clear guidance for staff about how to manage risks and mitigate the potential of reoccurrence. Staff did not always understand their responsibilities to ensure people were given choices about how they lived their lives and consent to care was not always sought in line with current legislation. People’s food and fluid intake was not always accurately monitored to ensure that they were protected from the risk of dehydration. Staff had not completed essential training or received annual appraisals and did not have access to regular supervision to support their professional development. The provider and failed to maintain a clear oversight of the service. We gave the home an overall rating of requires improvement and rated the area of effective as inadequate. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the quality of the service.

At this inspection, we looked to see whether the provider had implemented the action plan. We found the provider had made the required improvements to improve the standard of care and they were no longer in breach of any regulations. Since the last inspection, the provider had appointed a new registered manager. 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.

Following the previous inspection improvements had been made to people’s risk assessments. They now reflected people’s needs and contained clear guidelines for staff to protect people from harm. Staff received training on how to recognise signs of abuse and were clear about what action to take if any concerns arose.

Staff sought consent before providing care and consistently worked in line with the legislation of the Mental Capacity Act 2005 and no unnecessarily restrictive practices were in place. Since the previous inspection, the service had commissioned a new training provider to deliver training to staff on how to support people with dementia who may be resistive to personal care; In addition, one-page profiles highlighting key risks and how best to support people were in each person’s daily files.

Staff had completed a variety of training sessions. This meant people received care from skilled staff who were able to meet their needs. Staff received supervision and annual appraisals to support them in their role and identify any learning needs and opportunities for professional development.

Staff had completed nutritional assessments. Where people were found to be at risk of malnutrition or a low fluid intake this was clearly recorded in their care plans, and staff effectively monitored and recorded their food and fluid intake. Where staff had identified concerns about people’s nutritional status specialist advice was sought from healthcare professionals such as the dietician and speech and language therapist.

The service had a robust recruitment process in place to ensure that staff had the necessary skills and attributes to support people using the service. New members of staff completed an induction programme during which they completed training sessions and were introduced to, and spent time with, the people that

Foxburrow Grange is registered to provide accommodation and nursing care for up to 66 older people, some of whom are living with dementia. The service is split into four units, each of which has nursing staff based on it to support people who require nursing care. On the day of the inspection there were 63 people living at the service.

The last comprehensive inspection of the service took place on 26 February 2015, at which time the service was rated as good. Following the receipt of information of concern relating to the safe care and treatment of people living at the service, person centred care, staffing levels and the management of the service a further responsive inspection took place on 21 December 2015. This inspection focused on the domains of safe and well-led and rated both areas as good.

We carried out the most recent inspection in response to concerns about the high number of safeguarding alerts raised by the service and problems highlighted by the local authority Quality Improvement and Organisational Safeguarding teams. The concerns were primarily in relation to the safe care and treatment of people using the service, insufficient staffing levels and ineffective leadership of the service.

The inspection took place across three days. The visits on 10 and 30 March 2017 were unannounced. The final inspection visit on 6 April 2017 was announced, during this visit we predominantly looked at the paperwork relating to staff files and the safety and maintenance of the service.

During the inspection we found that the provider was not meeting the legal requirements in multiple areas of the home. Following the first day of the inspection an urgent action letter was sent to the provider highlighting the concerns that we had found and requesting them to provide an action plan detailing the measures that they planned to implement in order to address these concerns. When we returned to the service for the second day of the inspection we found that the service had made some progress in addressing the concerns highlighted but continued improvements were required to ensure that people living in the service received safe, effective care from staff who had the necessary skills and knowledge to fulfil their roles.

On the first day of the inspection there was a registered manager in post at the service. 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. However, during the process of the inspection we were informed by the director of operations that the manager had resigned from their position and the service had appointed a new manager who was in the process of registering with the commission.

There were not enough suitably trained staff on all the units to ensure that people received safe care and support that was tailored to meet their individual needs. The service had failed to ensure that staff received appropriate training and support to help them develop the knowledge and skills needed to provide care which met the needs of people. This meant that the care provided did not consistently ensure that people were calm and settled and able to live full lives.

Across the service there was a heavy reliance upon agency nurses and care workers. This meant that people did not consistently receive care from staff who knew them well or who they knew and trusted.

The service had a system for monitoring accidents and incidents. However, not all staff had an understanding of what constituted an incident and therefore the correct process to report it had not been followed.

The service had a recruitment process in place to ensure that staff were safe to work with people living at the service.

The provider had not consistently worked in accordance with th

We undertook this focused inspection to assess the level of risk to people who used the service following information of concern we had received. Concerns included the safe care and treatment of people using the service, person centred care, sufficient and skilled staff and the management of the service.

This report only covers our findings in relation to the location being safe and well-led. You can read the report from our comprehensive inspection carried out 26 February 2015 by selecting the ‘all reports’ link for Foxburrow Grange on our website at www.cqc.org.uk. In the comprehensive inspection Foxburrow care was meeting the standards and had been rated as ‘Good’.

Foxburrow Grange is a residential home providing accommodation with nursing care for up to 66 people in four separate units. Two of the units provide dementia care. On the day of our visit, 50 people were using the service.

On the day of our inspection, there was no registered manager in post. However, an application to be the registered manager with the Care Quality Commission had been made by a senior member of staff. The Head of Dementia Care had responsibility for the management of the service whilst this was in progress.

We found that improvements had been made to the management of the service and to people’s safety and wellbeing.

The service had appropriate systems in place to keep people safe and staff followed these guidelines when they supported people. There were sufficient numbers of care staff available to meet people’s care needs and people received their medicine as prescribed and on time.

The provider had a robust recruitment process in place to protect people and staff had been recruited safely. Staff had the right skills and knowledge to provide care and support to people.

There was a strong manager who was visible in the service and worked well together with the team. People were well cared for by staff who were supported and valued.

Management systems were in place to check and audit the quality of the service. The views of people were taken into account to make improvements and develop the service.

We carried out this inspection on 26 February 2015 and it was unannounced.

Our last inspection of the service took place on 23 June 2014 and we found the service was meeting the requirements of the regulations we inspected at the time.

Foxburrow Grange is a residential home providing nursing care for up to 66 people in four separate units. Two of the units provide dementia care. On the day of our inspection, there were 48 people living at the home.

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. The registered manager was present on both days of our inspection.

The service ensured people were protected from abuse and followed adequate and effective safeguarding procedures. We found care records were personalised and contained all the information needed for staff to provide safe care that met the needs of the person using the service.

People were supported to maintain their nutritional health and had enough to eat and drink. The food was praised by the people we spoke to during our inspection.

We found that medicines were stored and administered safely, by staff who were suitably qualified to do so.

We found good practice in relation to decision making processes at the home and in line with the Mental Capacity Act 2005 (MCA) Code of Practice, with the principles of the MCA and Deprivation of Liberty Safeguards being followed.

We found that staff were kind and caring and treated people with dignity and respect.

There were good quality-monitoring systems in place at the home that were carried out on a regular basis. We saw that, where issues had been identified, the home had systems in place to ensure that appropriate learning could take place.

This was the first inspection of Foxburrow Grange since the home opened in July 2013. Three of the four units were occupied at the time of our inspection. During our inspection we spoke with four people who were living at the home and two relatives. We also spoke with the director of operations who was providing management cover in the manager’s absence. We spoke with the clinical lead and a number of the nursing, care and support staff. We also spoke with the manager following the inspection.

During our inspection we gathered evidence to help us answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well-led?

Below is a summary of what we found. The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

People told us that they felt safe in the home. One person said, “I feel safe here. It’s an excellent place to stay.” A relative we spoke with said: “I feel (my relative) is safe here.” People told us that they felt their rights and dignity were respected and they felt in control of decisions about their care and support. There were systems in place to protect people from poor practices or abuse.

There were systems in place to ensure that managers and staff learnt from events such as accidents and incidents, complaints, whistleblowing and investigations. There was evidence of actions taken to address issues raised whenever this was needed. This helped to reduce the risks to people and encouraged the service to continually improve.

The service had made applications under the Deprivation of Liberty Safeguards (DoLs) in order to keep people safe. The clinical lead was in the process of reviewing all the people in the home who might need an application made under DoLs. This was to ensure that where a person lacked capacity, and an application had been authorised to deprive them of their liberty, any decisions were made in their best interests.

Is the service effective?

People told us that staff were effective in meeting their needs. One relative told us: “Staff treat (my relative) as an individual and meet their individual needs.”

Is the service caring?

People were supported by respectful, supportive and attentive staff. People we spoke with were all complimentary about the staff and told us that they were “very caring” “helpful” and “friendly”. Both the relatives we spoke with praised the staff. One of them said, “The staff are friendly, calm and smiling. They are very caring. They seem to enjoy their job.” The other relative told us, “Staff are respectful and caring.”

Is the service responsive?

People we spoke with told us that the staff were responsive to their requests and to changes in their needs. One person said: “I ring the bell and they come running.” A relative described how staff responded extremely promptly to changes in people’s medical condition. They told us, “(My relative) wasn’t well over the weekend and they got the out of hours GP out. They communicate with me very well” A person living in the home said, “If you’re not well you can stay in bed. I go to bed when I want to.”

Is the service well led?

The levels of staff training and supervision needed to be improved, so that staff were supported to deliver care and services safely and effectively. Since the opening of the home in July 2013 the original manager had resigned in November 2013. The director of operations and a short term interim manager had also covered the home before the current manager was appointed in April 2014. The home had also used a number of bank and agency staff to fill vacancies. This had led to some variations in the management approach and on occasions difficulty in maintaining consistent standards. Agency staff usage had reduced considerably at the time of our inspection and continuity of care had now improved.

The service had a commitment to continuous quality improvement and an open culture. The service worked well with other agencies to ensure that people had continuity in their care. Staff, people and relatives appreciated that they now had stable management. A relative told us, “Since the new manager took over the place has been running better.”

All the staff we spoke with told us that they enjoyed working at Foxburrow Grange. A member of staff said, “The management is good. We’re a good team. We have regular meetings and communication is good. We all support each other.” A relative described the management as “open and understanding”. Another relative told us, “They are very good at dealing with complaints. They have good systems in place.”