We recently undertook an inspection visit to Fosse Court on a planned inspection. We looked at the following areas to ascertain the findings of this report and answer our five 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 summary is based on our observations during the inspection and what we learned when we spoke with people using the service. We also spoke with and observed the staff group and obtained information from the records we looked at.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Safeguarding procedures were in place and staff understood how to safeguard the people they supported. People told us they felt safe. The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made, and in how to submit an application.

The registered manager compiled the staff rotas, which took people’s care needs into account when making decisions about the staffing numbers required. The staff recruitment practice was safe and thorough. No staff had been subject to recent disciplinary action. A recruitment policy and procedures were in place to make sure that an equitable and safe process was undertaken and people were protected.

The service was safe and equipment was well maintained and serviced regularly. We looked at the medicines that were held and distributed to people in the home. We found that the medicines were not managed appropriately. We found that improvements were required around the storage and administration of medicines.

Is the service effective?

There were contact details available for an advocacy service if people needed them. That meant that if required people could access additional support. People’s health and care needs were assessed, and they and their representatives were involved in the agreement of their plans of care. We saw that people were treated with respect and dignity by staff.

Is the service caring?

The service worked well with other agencies and services to make sure people received care appropriate to their needs. We saw where people were supported by visiting doctors, specialists and district nurses on a regular basis. People were supported by an ethnically appropriate staff group. People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People were offered a range of activities both in and outside the service. The home has its own transport, which was used to take people to the local temples and for other outings. We found that people’s equality and diversity was respected and appropriate arrangements were in place. For example, people received care and support from staff who spoke their preferred language.

Is the service well-led?

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. People using the service and their relatives, were invited to complete an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

We spoke with five people who used the service and four members of staff. We also reviewed four care records.

We noted where people had varying ability to understand and retain information, strategies were documented on how best to communicate and ensure information was understood. For example, in one care record we saw that one person benefited from information being given in their first language and repeated several times to ensure comprehension.

We observed the lunchtime meal in the dining room. Staff took their time to ask people what they would like and interacted positively. During our visit we also sampled the lunchtime menu and found it to be tasty and varied.

The care records reviewed demonstrated that risk assessments were conducted for people who used equipment. We also saw that a moving and handling assessment was undertaken in conjunction with the equipment risk assessment.

On the day of our visit we found five members of staff on duty to care for 18 people who used the service. We observed good interaction and on many occasions noted that staff had time to sit and chat with the people using the service.

We asked one person who used the service what they would do if they were unhappy. They told us: “I raise issues as they arise. My comments are always listened to and dealt with.”

We received serious concerns about the management of the service along with information of concern alleging the abuse of people using the service. We referred the information immediately to the local authority and to the Police for investigation. We also carried out this responsive inspection to check on the safety and welfare of people.

During our inspection on 1 and 7 July 2014, we spoke with 15 people using the service in their own preferred language. We also spoke with the registered manager, care staff, the provider, the acting manager, the compliance manager employed by Fosse Court, a representative of Fosse Court and consultants appointed by the provider at the time. We looked at people’s care records and also reviewed the records in relation to the management of the service. We considered all the evidence we had gathered under the outcomes we inspected.

On 1 July 2014, four staff were suspended following the information of concern we received. The local authority had therefore arranged for their staff to support Fosse Court staff in the carrying out of the regulated activity. This was done with the provider’s permission with clarity that the provider continued to be accountable for the delivery of care during this time. The local authority staff provided this support from 1 July 2014 until 9 July 2014. This report also includes the information received from the local authority staff, which included their observations of the care provided, people’s safety and wellbeing and examples of staff practices. On 7 July 2014, we were given confirmation by the provider that they had suspended six staff members.

Due to the serious concerns to people using the service, the local authority made provisions to find safer alternative accommodation and care for people at Fosse Court. Once this decision was made, the local authority informed us the provider had made a decision to close the home on 9 July 2014. The provider later informed us this was because they did not wish to continue running a service that was considered to pose a risk to the service users. All the people using the service were moved out of Fosse Court by 9 July 2014.

Is the service safe?

We found systematic failures that resulted in people receiving care and treatment that was neither, safe or appropriate. The lack of proper assessment, care planning and delivery of care meant that people did not receive the care and support they needed. People were unkempt and we found that staff had not supported them properly to meet their personal hygiene. During our inspection we found people’s care records did not contain all the basic and essential information needed to meet their individual needs. We saw that people’s health and wellbeing was not monitored consistently. For example, arrangements had not been made for people who urgently needed to see other healthcare professionals, such as dentists, dieticians and chiropodists.

People did not have a choice of meals that suited their dietary requirements and preferences. We found that although some people’s weight was recorded, action had not been taken when required. The home brought in meals, which were cooked on another site. People were offered the same meals at tea time that they had at lunch. On the first day of our inspection we found the kitchen was not functional and there were food items which were out of date. We and the local authority brought this to the provider’s attention, later 15 refuse sacks of out of date food was disposed. On the second day of our inspection the kitchen was fully functional, food had been purchased by the provider and staff were seen preparing meals for people.

Throughout the home there were environmental risks such as uneven flooring, threadbare carpets and lamps or lights in people’s bedrooms which did not work. There were no locks on bedroom and bathrooms doors, which meant people’s privacy and dignity could not be maintained. The local authority informed us they found fire doors were wedged open, which increased the risks to people’s health and safety in the event of a fire.

We monitor the operation of the Deprivation of Liberty Safeguards (DoLS), which applies to care homes. The staff training plan showed that the registered manager and staff had not received any training to help promote people’s rights and their liberty. We saw that people’s care records did not include information about their mental capacity, or safeguarding. The service provided care for vulnerable people and we found that some people did lack the capacity to make decisions about their care and treatment. However, there were no completed capacity assessments or the involvement of other professionals in determining this. It was unclear how decisions were made in people’s best interests.

People were at risk of not receiving their correct medicines at the right time. The arrangements in place in relation to the administering and auditing of medicines were not appropriate and effective. During our inspection we observed staff did not administer medicines safely, medication administration records were not completed accurately and the process had not been audited to identify these shortfalls. There was no policy and procedure that staff could follow to clarify the administration or auditing process. The provider had failed to make the necessary improvements they told us they would make following our inspection on 3 April 2014.

We found there was a systematic failure on the part of the registered provider, registered manager and staff to protect people from harm.

We found that when looking at selection and recruitment processes for staff, these were in place. However, we were unable to establish from the records and our discussion with the provider, whether a staff member had the right to work in the United Kingdom. We have referred this to the relevant authority.

Is the service caring?

People did not always receive the support they needed from staff. People shared their experiences that demonstrated staff did not listen or support them when required in a caring manner. We observed that staff ignored a person who requested help. The comments we received from people included: “They never come when I call them. They do not help me. They trouble me a lot by not coming” and “They do shout at people saying come on hurry up. If someone (people using the service) is shouting, they (staff) shout back”.

Is the service effective?

We found people did not receive effective or appropriate care and treatment. People were not supported to be involved in the assessment and care planning process to help ensure they received the support needed. Staff were not fully aware of people’s needs, which had the potential risk of their needs not being met. We found people did not always experience a good quality of daily life. We saw that staff interactions with people were take orientated and there were no meaningful activities for people. One person described that the only thing there was to do, was to watch television.

Is this service responsive?

People told us that staff did not respond to their requests for assistance. We found that some call bells were either not accessible, not working or missing. This meant people could not summon assistance or use in an emergency. The local authority found this to be case numerous times between 1 July 2014 and 9 July 2014. We found that people’s basic care needs were not met properly and risks were not managed to support them.