Foxburrow Grange

Systems were in place and being used for managing safeguards, but on occasion they were not given sufficient priority, or reported to the local authority for advice, as per the provider's own guidance.

Systems to identify and address potential risks to people using the service, had improved. Management and staff had worked well with the dementia specialist team to develop a risk-based approach to effectively support people whose behaviour can sometimes present a risk to themselves, or others. Routine checks were now being carried out on clinical equipment, bed rails and wall bumpers to ensure these were safe and in good working order. However, further improvements were needed to ensure electrical sockets were assessed against the risks of tampering with and the risk of electric shocks or burns.

People were supported to eat and drink enough to maintain a balanced diet. However, staff did not always have access to up to date and reliable information about peoples' specific dietary needs and choking risks. Whilst no people had come to harm, where changes had been made to their diets, such as changes in the size, texture or consistency of foods and fluids, these had not always been updated in their care records in a timely way. Therefore, staff did not always have the correct information to support people to eat and drink safely. Immediately following the inspection, the registered manager told us they had reviewed people's records to ensure they contained accurate information. They had also sought additional training through the SaLT team for all staff, including catering staff to improve their understanding of managing dysphagia.

Staffing levels were reviewed on a regular basis to ensure there were enough staff deployed across the

service. However, we observed, and staff told us, they struggled to meet the changing needs of people in Hedgehog unit. The registered manager agreed to review staffing numbers on Hedgehog unit to ensure people received timely care and support.

The service had made significant improvements to the management of medicines. However, improvements were needed to make sure people prescribed time sensitive medicines were given these within the recommended time frame. We have made a recommendation about following national guidance for administration of medicines.

Staff were recruited safely. Staff had received support, induction and training they needed which gave them the skills and knowledge to meet people's needs. The service worked well with other professionals to understand and meet people's needs. Staff supported people to live healthier lives, and access healthcare services. A 'Smiling Matters' approach had been implemented to promote people's oral hygiene.

Peoples' privacy, dignity and independence was respected. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People's risk assessments and associated care plans needed further development to ensure they were current, reliable, and relevant. Summary and extended care plans contained repetitive information which had the potential to cause confusion and/or error in the delivery of people's care. We have made a recommendation about care planning.

Staff were not always responsive to people's needs. People told us, and records showed staff response to managing pain, was not always dealt with quickly enough. The registered manager had recognised improvements were needed in relation to end of life care. They were working with their local hospice developing training and support for all staff to improve advanced care planning, communication, and having uncomfortable conversations about death and dying.

Our previous inspection found the leadership and governance systems to assess and monitor the quality and safety of the service were ineffective. At this inspection we found Improved auditing process, including a monthly governance report which were identifying where improvements were needed, and the action taken. However, further improvements were needed to ensure governance systems encompassed the wider quality and safety issues we identified during this inspection. This included staffing levels / deployment of staff / quality and accuracy of information about people's care needs and how they are to be supported.

We have made recommendation about quality assurance arrangements.

Improved analysis of incidents and accidents had led to a decrease in falls. Investigations into incidents to establish the cause were completed and learnt from to improve safety across the service.

Information received before and during the inspection reflected ongoing concerns about a poor culture across all departments. This focused on unsupportive management, and a lack management presence on the floor. Work was in progress in conjunction with the provider's human resources to reach out to staff to improve morale, communication, and effective team working.

The management team had developed a range of ways to engage with people, their family, friends, and staff in a meaningful way. These included feedback from questionnaires, a family forum and a twice monthly newsletter to keep people and their relatives informed of any changes in the service and upcoming events.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk