Foxby Hill Care Home

The provider did not have effective systems in place to ensure responsive learning from incidents. People were not always fully protected from risks associated with choking, burns and damage to their skin. The provider did not always follow the principles of the Mental Capacity Act 2005 (MCA) and systems to track and monitor Deprivation of Liberty Safeguards (DoLS) authorisations were not always effective. The provider did not always detect and control environment risks and medicines management was not always effective at identifying and minimising risk. The service supported people with safe transitions into the service.

Risk assessments did not fully explore risks associated with people's care and treatment. Mealtimes were not appropriate to promote good nutrition, and people did not have access to fresh fruit, vegetables or salads. Staff did not always work effectively to ensure people’s daily needs were met. Staff mostly demonstrated care and compassion for the people they supported. However, systems of care did not always promote people to live healthier lives. Where people lacked mental capacity, assessments were not in place to ensure the provider understood how best to support them with decision making.

The service lacked consistent leadership. Staff mostly described a positive workplace culture, but some staff stated the lack of consistent leadership made things difficult. Staff did not always feel they could speak up and that their voice would be heard. Quality assurance and oversight processes were not always effective. The service was not always forth coming with identifying and escalating concerns of people’s deteriorating health and was sometimes resistant to working with other services. Oversight systems were not effective at ensuring timely improvement.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded. We have asked the provider for an action plan in response to the concerns found at this assessment.