Fox Elms Care Limited was rated Requires Improvement overall, with breaches of Regulation 17 (Good Governance) identified in both safe and well-led domains due to inconsistent care records, inadequate oversight, and gaps in medicines management including covert administration and epilepsy care plans. A new senior management team had begun implementing improvements, but further time was needed to embed changes and ensure interim safety measures protected people from risk.
Concerns (10)
criticalGovernance: “systems were either not in place or robust enough to demonstrate the service was effectively managed. This placed people at risk of harm. This was a breach of regulation 17.”
criticalRecord keeping: “records relating to people's care were not always comprehensive and up-to-date. This placed people at risk of harm.”
criticalCare planning: “People who have a diagnosis of epilepsy did not always have clear guidelines and protocols for staff to follow to support them safely.”
moderateMedication management: “we could not be assured that other medicines information in care records was always up to date or readily available when needed.”
moderateMedication management: “for one person we could not see the record to support the decision to give medicine covertly.”
moderateStaffing levels: “people had not always received correct staffing levels or expertise from staff who knew them well.”
moderateLeadership: “Staff did not consistently know and understand the provider's vision and values. One staff member said, 'I don't know what [the Provider] wants and I don't know what they stand for.'”
moderateCommunication with families: “One relative said, 'I haven't seen the care plan and there's quite a few times that the phone hasn't worked for weeks and weeks.'”
moderateIncident learning: “We saw evidence that encouraged reflective practice following medicines incidents however, we did not see evidence to prevent future occurrences.”
minorInfection control: “Staff did not consistently wear PPE in line with the guidance and providers policy.”
Strengths
· Staff understood safeguarding responsibilities and could describe types of abuse, signs of concern, and reporting procedures.
· Staff followed STOMP principles, ensuring behaviour was not controlled by excessive or inappropriate use of medicines.
· Recruitment was conducted safely, including DBS checks and references before staff worked with people.
· The service worked within the principles of the Mental Capacity Act and appropriate DoLS authorisations were in place.
· A new senior management team implemented a service improvement plan prior to inspection and had made considerable progress.
Fox Elms Care Limited (now under Voyage Care ownership) was rated Requires Improvement overall following a focused inspection in October 2020, with both Safe and Well-Led domains remaining at Requires Improvement from the previous inspection. Key concerns centred on three unreported safety incidents, ongoing medication errors, out-of-date care plans, and inconsistent governance and leadership stability following the change of ownership.
Concerns (6)
criticalIncident learning: “there had been three safety incidents between people that had not been reported appropriately. This placed people at risk as the provider could not check whether people had been supported safely”
moderateMedication management: “investigations into three recent medication errors and discrepancies with medicines stock were being conducted by the service.”
moderateCare planning: “people's support plans and risk assessments had not always been reviewed to reflect people's current needs and levels of risk.”
moderateGovernance: “auditing of care plans, these checks had not always been fully effective in identifying shortfalls in people's records to ensure they remained up to date”
moderateLeadership: “The frequent management changes are disconcerting. A number of staff across the service had left since the change of ownership.”
minorRecord keeping: “Risk assessments, care plans and behaviour plans were in place...but further work was needed to ensure that these plans were regularly reviewed and kept up to date”
Strengths
· Staff were knowledgeable about safeguarding procedures and confident in identifying and reporting abuse.
· Robust recruitment process including DBS checks, right-to-work verification and conduct references.
· Sufficient staffing levels in place; all staff spoken with confirmed enough staff on duty to keep people safe.
· Strong COVID-19 infection prevention and control measures including PPE, temperature checks and surplus stock.
· Medicines stored securely with trained and competency-assessed staff administering them.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements
Fox Elms Care Limited received a Good rating across all five key questions at its unannounced inspection in February 2016, demonstrating person-centred, safe and well-managed care for 26 people with learning disabilities, physical disabilities and mental health needs. Minor gaps in recruitment record-keeping and post-incident debriefs were identified and addressed during the inspection.
Concerns (3)
minorRecord keeping: “two of the five staff files examined had failed to do this [provide full employment history]. During the inspection this was rectified”
minorSupervision / appraisal: “debriefs with senior staff after accidents and incidents...had been offered, they not always been carried out so missing the opportunity to learn and evolve”
minorPerson-centred care: “still needed to encourage people to get out and about, to be more independent and to have greater community access”
Strengths
· Personalised care records reflecting individual preferences, routines, aspirations and communication methods including sign language and objects of reference
· Strong staff knowledge of safeguarding procedures with prompt escalation to local authority safeguarding team when concerns arose
· Medicines administered safely with staff trained and observed for competency; pharmacy blister pack error identified and reported by staff
· Robust positive behaviour management training accredited by the British Institute of Learning Disabilities
· People involved in staff recruitment including attending interviews; continuity and consistency of staffing maintained without use of agency staff
This focused unannounced inspection of Fox Elms Care Limited, prompted by a notified incident involving a death under coroner investigation, examined the management of choking and other risks for 25 people receiving personal care. The service was found to remain Good for safety, with robust risk assessments and care plans in place, though minor inconsistency in the detail of some choking care plans was identified and actioned.
Concerns (1)
minorCare planning: “Two care plans referred the reader to the speech and language therapist recommendations and to their risk assessments without detailing the content in the care plans.”
Strengths
· People's risks were assessed with detailed care plans cross-referenced to risk assessments covering choking, epilepsy, self-harm and transport
· Speech and language therapy guidance was transferred into care plans with specific instructions for managing choking risk based on mood and food type
· Accident and incident records were monitored for trends and health care professionals were consulted for advice on risk management
· Staff completed training in individual risks including dysphagia, epilepsy emergency medicines and first aid
· Each person had an individual personal evacuation plan and the service worked with the local fire brigade to enhance fire safety
Fox Elms Care Limited was rated Good overall at its February 2019 inspection, with a Requires Improvement rating for Safe due to unclear medication administration records, inaccurate controlled drug recording, infection control shortfalls in one location, and inconsistent use of agency staff. The remaining four key questions were rated Good, with strong person-centred care, positive feedback from relatives, effective quality assurance systems, and committed leadership recognised as notable strengths.
Concerns (8)
moderateMedication management: “The MAR for one person had been changed by the staff but the changes were not made clear. Staff had crossed duplicate medicines in the MAR but had not detailed the reasons for this.”
moderateMedication management: “There were people that were prescribed with medicines that required stricter recording controls. Some staff showed a lack of awareness of these guidelines.”
moderateRecord keeping: “In two services staff had not kept accurate records of medicines received.”
moderateStaffing levels: “Agency staff are used most shift. Inconsistencies of care delivery when agency staff were used. Recruitment is a problem.”
moderateConsent / capacity: “Mental capacity assessments were not always in place for staff to administer medicines.”
moderateGovernance: “References from the previous employer was not requested for one staff. The assessment of risk was not documented.”
minorInfection control: “One of the three shared living locations that we visited was in need of better cleaning regimes. Housekeeping staff were not visiting and the support workers were having to undertake housekeeping regimes.”
minorSupervision / appraisal: “Some staff said they had not had regular one to one supervision meetings.”
Strengths
· Care plans were mostly person centred, incorporating people's life stories, guidance from community professionals, and individual risk assessments with action plans.
· Strong positive feedback from relatives, with staff praised for compassion, consistency and person-centred approaches.
· Quality assurance systems were in place with internal and external audits; shortfalls identified and action plans implemented.
· Accidents and incidents were reported and analysed for patterns and trends, with evidence of learning outcomes.
· Staff demonstrated good understanding of safeguarding procedures, MCA principles, and DoLS requirements.
Quality-Statement breakdown (22)
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentRequires improvement
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choicesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
Requires improvement
well-led: Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Planning and promoting person-centred, high-quality care and support with opennessGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood