This inspection was carried out on 16 January 2017 and was unannounced.

Foxholes Care Home provides accommodation and personal care for up to 110 older people some of whom live with dementia. At the time of the inspection there were 59 people living at the home. Following our previous inspection of the service on 04 December 2015 we imposed a condition on the provider’s registration to prevent them from admitting any further people to Foxholes Care Home because of the concerns found. At this inspection we found that the improvements made by the provider were sustained, the care people received was safe and effective. We took the decision to remove the condition for the provider to be able to admit people in the home.

There was a manager in post who registered with the Care Quality Commission. 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 also the provider.

When we last inspected the service on 8 June 2016 we found the service was meeting the required standards. However the governance around auditing, identifying and responding to concerns was not robust enough. At this inspection we found that the governance systems were effective in identifying any shortfalls and actions were in place to improve the quality of the care provided.

Staff obtained people’s consent before providing the day to day care they required. We found that processes to establish if people had lacked capacity for certain decisions were followed in line with the MCA 2005 and where necessary best interest meetings were organised to develop an effective plan of care for people. The registered manager had submitted Deprivation of Liberty Safeguards (DoLS) applications to the relevant authorities to ensure any restrictions applied to people`s freedom were in line with the current legislation. Some of these applications were still pending an outcome.

People were accommodated in a purpose built environment which was clean and well maintained. Bedrooms were personalised and had en-suite facilities whilst still providing specialist bathroom facilities, several communal areas, dining rooms, an orangery room, a shop, hairdresser room, quiet lounges. People were able to choose where they wanted to spend their time.

We found that staff were knowledgeable about people`s needs and any risks of them developing pressure ulcers. People who required were repositioned regularly and staff followed recommendations from health care professionals when offering care.

Staff received training and were knowledgeable in how to safeguard people from any risks of abuse. They were able to describe what constitutes abuse and the reporting procedure they would follow to raise their concerns.

People`s medicines were administered by trained staff who had a good understanding of safe medicine management practices. People told us they were seen by their GP regularly and staff were prompt in requesting a GP visit if they were in need.

The provider was monitoring people`s dependency levels and on the day of the inspection we saw senior staff re-deploying care staff to different units where there was a need for extra staff members. There was sufficient numbers of staff to meet people`s needs in a timely way.

People told us that the standard of food provided at the home varied. We saw that the meals served were hot and that people were regularly offered a choice of drinks. Staff monitored food and fluid intake for people who were at risk of losing weight and involved people`s GP and dieticians in their care to ensure people`s nutritional needs were met. People told us staff were kind and respectful in their approach. We observed staff were knowledgeable about people`s circumstances

This inspection was carried out on 8 June 2016 and was unannounced.

Foxholes Care Home provides accommodation and personal care for up to 110 older people some of whom live with dementia. At the time of the inspection there were 50 people living at the home. Following our previous inspection of the service in December 2015 we imposed a condition on the provider’s registration to prevent them from admitting any further people to Foxholes Care Home because of the concerns found.

There was a manager in post, who had submitted their application to register, however they were not yet registered with the Care Quality Commission. 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.

When we last inspected the service on 15 October 2015 and 4 December 2015 we found it was not meeting the required standards. We found breaches of the Regulations in relation to safe care and treatment, staffing, consent and good governance. At this inspection we found that the provider had made some improvements, however the governance around auditing and identifying and responding to concerns was still not robust enough and further improvements were still required.

Staff obtained people’s consent before providing the day to day care they required. We found that processes to establish if people had lacked capacity for certain decisions were followed in line with the MCA 2005 and where necessary best interest meetings were organised to develop an effective plan of care for people. The manager had submitted Deprivation of Liberty Safeguards (DoLS) applications to the relevant authorities to ensure any restrictions applied to people`s freedom were in line with the current legislation. Some of these applications were still pending an outcome.

People were accommodated in a purpose built environment which was clean and well maintained. Bedrooms were personalised and had en-suite facilities whilst still providing specialist bathroom facilities, several communal areas, dining rooms, an orangery room, a shop, hairdresser room, quiet lounges. People were able to choose where they wanted to spend their time.

At the last inspection we found that people were not always protected from harm, two people developed pressure ulcers whilst they were living at the home. At this inspection we found that staff were knowledgeable about people`s needs and any risks of them developing pressure ulcers. People who required were repositioned regularly and staff followed recommendations from health care professionals when offering care.

Previously when we inspected people told us that they felt their needs were not met safely at all times. They had to wait to use the toilet at times as staff took a long time to answer call bells. This time people told us staff were quick in responding to their needs and call bells were answered in time.

Staff received training and were knowledgeable in how to safeguard people from any risks of abuse. They were able to describe what constitutes abuse and the reporting procedure they would follow to raise their concerns.

When we inspected previously we found that people had not received their medicines according to the prescriber`s instructions, medicines were not managed safely. At this inspection the provider had made significant improvements. People`s medicines were administered by trained staff who had a good understanding of safe medicine management practices. People told us they were seen by their GP regularly and staff were prompt in requesting a GP visit if they were in need. Previously we were told by some people that they could only see their GP if staff agreed with them they needed it.

The provider was monitoring people`s dependency levels and on the day o

This inspection was carried out on 04 December 2015 and was unannounced.

Foxholes Care Home provides accommodation and personal care including nursing care for up to 110 older people. At the time of the inspection there were 62 people living at the home. There was a manager in post, who was not currently registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

When we last inspected the service on 15 October 2015 we found them to not be meeting the required standards. This was a focused inspection to check if they had made the improvements necessary to meet the required standards. We found that they were still not meeting the standards because there was not enough staff to meet people`s needs safely at all times, people`s medicines were not managed safely. Records were not contemporaneous and not completed in a timely fashion to reflect what care people needed or received. At this inspection we found that they were in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

People told us that they felt their needs were not met safely at all times. They had to wait a long time for staff to answer call bells. The manager has failed to monitor how long it took for staff to answer call bells and not listened to people`s concerns when they reported the shortage of staff. People`s nursing needs were not always met due to high numbers of agency nurses who were not familiar with people`s health needs.

People had their medicines administered by staff who were trained, however we found when we reconciled medicines for people there were more tablets that there should have been or less. This meant that people had not received their medicines according to the prescriber`s instructions.

The manager failed to action any of the concerns we reported in the previous inspection, they had not conducted any audits, they did not monitor the safety or the quality of the service provided.

This inspection was carried out on 15 October 2015 and was unannounced.

Foxholes Care Home provides accommodation and personal care including nursing care for up to 110 older people. At the time of the inspection there were 62 people living at the home. There was a manager in post, who was not currently registered with the Care Quality Commission. 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.

When we last inspected the service on 04 September 2014 we found them to be meeting the required standards. At this inspection we found that they were in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection some applications had been made to the local authority in relation to people who lived at the service. However not all applications were submitted as required by the recent changes of the Deprivation of Liberty Safeguards legislation.

Staff obtained people’s consent before providing the day to day care they required. We found that processes to establish if people had lacked capacity for certain decisions were followed in line with the MCA 2005, however staff had no clear guidance in how to ensure the care delivered was in the person’s best interest. There were no best interest meetings organised to develop an effective plan of care for vulnerable people. This meant that it was a risk that the care people received was not in their best interest.

People were accommodated in a purpose built environment which was clean and well maintained. Bedrooms were personalised and had an-suite facilities whilst still providing specialist bathroom facilities, several communal areas, dining rooms, orangery room, a shop, hairdresser room, quiet lounges. People were able to choose where they wanted to spend time.

People were not always protected from harm, two people developed pressure ulcers whilst they were living at the home. We found that people were not repositioned as it was recommended by professionals and this increased the risk of more pressure ulcers developing and delay in the healing process.

People told us that they felt their needs were not met safely at all times. They had to wait to use the toilet at times as staff took a long time to answer call bells. We also saw on one occasion when staff gave reassurance to a person in distress and promised they will come back to help them; we waited for 15 minutes however they did not return. Relatives told us they were happy with the care people received however they felt it was a need for them to visit daily and `keep an eye` on things.

The provider was monitoring people`s dependency levels and they recently adjusted staffing levels for nights as they recognised that people`s needs were not met safely. They also monitored how long it took for staff to answer call bells.

Staff had received training in how to safeguard people against the risks of abuse. They were able to describe what constitutes abuse and the reporting procedure they would follow to raise their concerns.

People had their medicines administered by staff who was trained, however we found when we reconciled medicines for people there were more tablets that there should have been or less. This meant that people had not received their medicines according to the prescriber`s instructions. People had access to health care professionals, there were regular visits form GP however some senior staff said they had to ask managers to for a second opinion if they wanted to ask for a GP visit outside the regular visits days.

People were concerned about staff leaving the service and the high number of newly employed staff members. They expressed mixed views about the skills, experience and abilities of the staff who supported them. We found that staff had received training relevant to their roles. Staff had regular supervisions to discuss and review their performance and professional development.

People told us that the standard of food provided at the home was good. We saw that the meals served were hot and that people were regularly offered a choice of drinks. Staff monitored food and fluid intake for people who were at risk of losing weight; however this was not done consistently. Most people told us staff was kind and respectful however they were concerned that staff was changing constantly and they were not able to develop long standing relationships.

People expressed mixed views about the opportunities available to pursue their social interests or take part in meaningful activities relevant to their individual needs. We saw that where complaints had been made they were recorded and investigated. However, there were no records to show that positive lessons had been learnt or that service delivery was improved from the complaints raised.

Staff was complimentary about the leadership of the home and they felt well supported in their role. There were several audits carried out regularly by the provider and the manager of the home; however the action plans developed following these audits were not revisited to ensure the outstanding actions were completed.

Prior to our inspection, we had received concerns that the service did not have sufficient and experienced staff to provide safe and appropriate care. The changes in the managers also meant that staff were not always supported, which had resulted in experienced staff leaving the service. We had also been told that the service's infection control processes were not sufficient to prevent the spread of infection.

Two inspectors from the Care Quality Commission (CQC) conducted this inspection. We gathered evidence against the standard we inspected to help answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The summary is based on what we found when we looked at the records, observed how people were cared for, and what people told us about their experiences of the service. We spoke with three people who used the service, a relative of one person, seven care workers, one member of the housekeeping staff, the provider, the new manager and a visiting health professional.

Is the service safe?

People's needs had been assessed and risk assessments described how any identified risks to people were minimised. We saw that the premises were clean and hygienic. The provider had effective medicine management processes in place and they kept people safe by responding promptly to any allegations of abuse. They also ensured that incidents and accidents were monitored and steps taken to prevent them from reoccurring. We saw that people were supported by sufficient staff, who were regularly trained to enable them to provide safe and appropriate care. We found the provider had effective systems to identify, assess and manage risks relating to the health, welfare and safety of people who used the service.

Is the service effective?

Detailed care plans were in place to provide guidance to staff on how to deliver appropriate and effective care. We also saw evidence that the provider sought additional support from other health and social care professionals, to ensure positive care outcomes for people who used the service.

Is the service caring?

We observed that people were supported by kind and attentive staff. From our observations and from speaking with the staff, we noted that they had a good understanding of the needs of the people they supported. The people we saw also appeared happy and well looked after. The relative of one person said, "The care is good. We looked at other homes and found this one to be excellent."

Is the service responsive to people's needs?

We saw that the care plans had been updated when people's needs had changed, and that referrals had been made to other health and social care professionals when required. The service took account of individual preferences, and people were supported to engage in a variety of activities. The service was responsive to people's concerns and complaints, and acted promptly to resolve these to the complainants' satisfaction.

Is the service well-led?

The service had recruited a new manager since our previous inspection in July 2014 and they were in the process of registering with the Care Quality Commission. We found the manager had made progress in improving the quality of the service's auditing systems to ensure that they had robust processes to regularly assess and monitor the quality of the service. They also ensured that records were well maintained and updated when necessary.

When we visited Foxholes Care Home in December 2013 we found that they were not meeting four of the regulations we reviewed. We checked to make sure they had made the required improvement and found that improvements had made been made.

In this report the name of a registered manager has been recorded, however, they were not in post and not managing the regulatory activities at this location at the time of the inspection. Their name has appeared because they were still on our register at the time of this inspection.

The inspection team was made up of two inspectors. We set out to answer our five questions.

Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection discussions with people using the service, the staff supporting them and looking at records.

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

Is the service safe?

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw evidence that the home had submitted standard authorisation request applications to the supervisory body. The relevant paperwork had been completed and we found this to be in line with the legislation.

We found where people were at risk of poor fluid and food intake and tissue damage risk assessments had been completed. These had been regularly reviewed to make sure information was current and reflected people’s needs.

Is the service effective?

We found that people had been provided with an assessment and their care and support needs had been documented in their individual care plans. This meant that information recorded in their care plans ensured that staff would be able to provide care and support to meet their identified needs.

We found that people were cared for by staff who were provided with regular supervision and appraisal. This meant that people were looked after by staff who were supported to deliver care and treatment safely and to an appropriate standard.

Is the service caring?

We asked people for their opinions about the staff who supported them. Comments from people were positive. For example, one person said, “They (meaning staff) are very good. They provide me with an excellent service.” Another person said, “Staff are dedicated.” A further person said, “Staff are kind and caring.” This demonstrated that people felt that they had developed a caring and positive relationship with the staff who were caring for them.

Is the service responsive?

We found that people’s individual needs were regularly assessed to ensure that the care and support provided to them met their diverse needs.

Is the service well-led?

Staff spoken with said that regular staff meetings were held and they were listened to and enabled to make suggestions and influence how people’s care should be provided. They also said that the management team was supportive and approachable.

During our inspection of Foxholes Care Home on 31 July 2013, we spoke with 12 people who lived there, four of their relatives, four members of care staff and the manager. We found evidence that the provider had failed to meet the essential standards of quality and safety in a number of key areas.

Although we saw some evidence that people’s wishes had been identified and acted upon, most of the people we spoke with could not recall having been involved in decisions about the planning and delivery of their care. One person said, “Never seen a care plan.”

Most people we spoke with told us they were happy living at the home. One person told us, “It's lovely living here. I really like it….rooms are lovely, great views and wildlife. It has lots to offer.” However, we found several examples of situations in which people's care needs had not been met.

We saw that people had been provided with appropriate levels of support where necessary to help them eat and drink. One person told us, “The food is excellent..” However, we found examples of where people’s nutrition and hydration needs had not been met.

We found that effective recruitment procedures had not been put in place, there had not always been enough staff to meet people’s needs and in some cases staff had not been supported to provide appropriate levels of care.

The provider had not put effective quality assurance systems in place, feedback had not been sought from people who used the service and some care records we looked at were incomplete.

When we visited the home on 9 November 2012 it had been open for six weeks and there were 11 people living in it. This number was rising as referrals were coming through. At our visit we spoke with six people.

People said they were involved in decisions regarding their own care and were given choices about how they wished to spend their days. Their preferences were taken into account and there was a choice of dishes available at meal times. People were well cared for and one person said, “The staff are very kind and helpful, there is always a member of staff nearby if I need anything.”

People said that they felt safe in the home. Staff had been safely recruited and were knowledgeable about safeguarding issues and how to handle them appropriately.

There was a system in place for monitoring and assuring the quality of the service. Feedback from people, their relatives and staff was taken into account in the planning of the service.

At a previous inspection on 31 July 2013, we found that certain minimum standards of quality and safety had not been met. We identified shortfalls in relation to how consent had been obtained from people, the levels of care provided, recruitment practices, staffing levels, support and training, the assessment of risks and service provision and record keeping.

We told the provider to make improvements and subsequently received an action plan which stated the home would be compliant with the regulations by 31 October 2013. During our inspection carried out on 03 and 04 December 2013, we found that some improvements had been made but there were still areas of non-compliance with the regulations.

We looked at records which showed that effective recruitment procedures had been put in place and that appropriate checks were carried out before staff began work. The provider had made arrangements to ensure there were sufficient numbers of suitable staff available at all times. We saw that systems had been introduced to assess the quality of service provision and to manage risks.

The provider had made improvements to ensure that staff were appropriately trained and supported to perform their roles. We found that record keeping in relation to both recruitment practices and the care provided to people had also improved. However, the regulations had still not been met so we have told the provider to make further improvements.

We found that consent had not been obtained from people before care and support was provided in all cases. We also found that care had not always been assessed, planned and delivered in a way that met people’s needs.