Our inspection took place on 10 July 2017 and was unannounced.

Foxleigh Grove Nursing Home provides accommodation and nursing care to older adults and people with physical disabilities. The service is in a large, period-style building with expansive landscaped grounds. The service provides ongoing care as well as respite stays. The service is located in a secluded part of Holyport, a village near Maidenhead in Berkshire. The service is registered to accommodate a maximum of 39 people. On the day of our inspection there were 35 people used the service.

The service must have a registered manager.

At the time of the inspection, there was a 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.

At our last inspection on 8 June and 10 June 2016, we asked the provider to take action to make improvements regarding people’s medicines management, infection prevention and control, compliance with the Mental Capacity Act 2005, and people’s nutrition. The provider sent us an action plan and we found the actions were completed.

People were protected from abuse and neglect. We found staff were knowledgeable about risks to people and how to avoid potential harm. Risks about people and the building were assessed, recorded and mitigated. Sufficient staff were deployed and the registered manager had an appropriate system in place for review of staffing numbers. Medicines management was safer, and the service had worked with both the clinical commissioning group (CCG) medicines team as well as the community pharmacist to improve their practices.

Staff training and support had improved. There was a better focus on improving staff knowledge, experience and skills to provide good care for people. The service had improved compliance with the Mental Capacity Act 2005 and associated practices. People’s nutrition management had also improved. Appropriate access to community healthcare professionals was available. We saw some refurbishment was completed to modernise the building. We made a recommendation about the continued internal refurbishment of the premises.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People and others told us staff were kind and caring. People and relatives were able to participate in care planning and reviews, but some decisions were made by staff in people’s best interests. An improved focus on people’s care participation was required, and we made a recommendation about this. People’s right to privacy and dignity was respected.

Care plans were detailed, personalised and reviewed regularly. Some information held in computer-based systems did not match the care the person experienced. The service was receptive of our feedback about this. There was a satisfactory complaints system in place which included the ability for people and others to escalate complaints to external organisations.

There was an increased focus on the safety and quality of people’s care. This was led by the head of care and registered manager. Checks and audits were in place to measure the safety and quality of care. Staff demonstrated a positive workplace spirit and enjoyed their roles.

Foxleigh Grove Nursing Home was originally a large private house dating back to the late 18th century. The owners improved the fabric and furnishings of the building and carefully designed extensions were added in order to preserve the character and dignity of the original house. Full registration to care for older adults and people with disabilities was obtained and they admitted the first residents in 1983. The location is now registered to accommodate 39 people. The service is located in Holyport, a scenic village near Maidenhead in Berkshire. The service is surrounded by expansive landscaped gardens.

At the time of the inspection, there was a 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.

The location was last inspected under the 2010 Regulations on 3 December 2013, where the five outcomes we inspected were compliant. This is the first inspection of the location under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they felt safe living at Foxleigh Grove Nursing Home. People were safe from abuse and neglect. Staff we spoke with were knowledgeable of how to act if abuse occurred and how to report this to managers or other authorities.

Proper maintenance of the premises and grounds was evident. The registered manager and maintenance staff were knowledgeable about risks from the building and completed assessments and coordinated repairs to effectively prevent harm to people. We made a recommendation regarding Legionella prevention and control.

The service had robust recruitment procedures and detailed personnel files. People we spoke with told us staffing levels met their needs. People’s common statement was that call bells were not always answered in a timely manner. When we spoke with nursing staff and care workers, they felt that staffing levels were sufficient. We examined records about staffing deployment and observed staff perform their roles. We found that during peak periods, like meal times, staff were busy but that safe deployment was evident.

Medicines were not always ordered, stored, administered or recorded safely. This meant that people were at risk of medicines errors. This was confirmed by pharmacist audits. We advised the provider to seek guidance and support to ensure people’s medicines were safely managed.

Infection prevention and control practices required improved. The service was clean and tidy but national best practice for cleaning processes was not implemented. Some risks regarding chemicals were not mitigated by the provider.

Staff training, supervision and performance development required some improvement. Although induction programmes and training had occurred, competency checks and repetition of training was needed to ensure effective care. The provider sent us information after the inspection which demonstrated they listened to our findings and took action to ensure effective staff knowledge and skills.

The service was not compliant with the requirements of the Mental Capacity Act 2005. In some cases people were deprived of their liberty without the required legal authorisation. The registered manager explained they were aware and that actions had commenced to remedy this issue. We made a recommendation about the service’s compliance with the requirements of the Mental Capacity Act 2005.

People received nutritious food which they enjoyed. Hydration was offered to people to ensure they did not become dehydrated. However, there were some risks about malnutrition that were not detected by staff or the service. The computer documentation system contributed to incorrect risk scores for people. This meant people were placed at risk and some ha

We saw that people were well cared for and treated with respect and dignity. One person said, ‘‘it’s like a luxury hotel, I have no worries I just have to enjoy myself’’. Relatives of the people who lived in the home said, ‘’’the care can’t be faulted’’.

We found that people were offered a varied and balanced menu and were helped to eat and drink enough to keep them as healthy as possible. People were given a choice of freshly prepared food. People told us that the food was ‘’delicious’’.

The home had a robust recruitment process to ensure staff were suitable and safe to work with the people who lived in the home. We found that there were enough properly trained staff to meet people’s individual needs. People and their relatives described staff as ‘‘wonderful’’.

We found that the home had ways of looking at the care they offered so that they could make sure they maintained and improved it. They listened to the views of the people who lived in the home. People told us that ''the manager and the boss (provider) always listen to us’’. Relatives said, ‘‘the manager and staff are totally responsive, listen to you and take action straight away’’.

People who use the service and their relatives were complimentary about the staff and their skills and experience. One relative had written, “We are all very grateful for the monumental effort put into motivating mum”.

We observed staff interacting with each other and with people who use the service and saw that they were not rushed and provided care in a responsive manner.

The registered manager informed us that since our last inspection, new care workers had also been employed to increase the number of staff available for preparing the rota. The business manager told us that external agency staff were still used, although reliance on the agency for staffing was decreasing as more permanent staff were recruited.

At this inspection, the provider demonstrated a system had been introduced to determine the level of dependency for each person. This helped determine the number of staff and hours required to ensure people were safe.

Although we spoke to people who use this service we also spoke to their relatives and an external health professional who worked with this service. This was because some people who use the service were not able to communicate and we needed to gather more information on their care.

We saw people received appropriate care and treatment from this service. People told us staff were good at providing care and knew people's individual needs. We found people's care needs were reviewed frequently by the service and external professionals where necessary. However people who use the service, their relatives and staff told us there were sometimes delays in people receiving the care they needed because there were not enough care workers on duty at all times.

A relative of someone who uses the service said they were involved in their relative's care planning. Staff said there was ongoing communication with people who use the service, and their relatives where appropriate, about people's care.

We saw care plans and records relevant for the management of the service were appropriate and up to date. Care plans included mental capacity assessments and deprivation of liberty safeguards (DoLs) evaluations.

We found the provider had not reported to us incidents as required, which concerned the provision of care and welfare to people who use the service.

Generally people said they were well cared for and the staff were ‘very good’.

People told us that staff respected their privacy and dignity.

People said the home was kept clean and well maintained and they felt safe in the environment.