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CQC report explained · a residential care home, run by Orders of St John Care Trust

OSJCT Foxby Court

Middlefield Lane, Gainsborough, DN21 1QR

Requires improvementpublished 11 January 2024, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask
Safe?
Requires improvement
Inspectors found risks were not always well managed. These included repositioning, care plan information, medicines storage and infection control.
Effective?
Good
This question was not inspected during this visit. Its previous rating was carried forward, but the report does not state that separate rating.
Caring?
Good
This question was not inspected during this visit. Inspectors nevertheless saw caring support and a person-centred approach.
Responsive?
Good
This question was not inspected during this visit. Inspectors said staff showed good knowledge of people's needs.
Well-led?
Requires improvement
Quality checks did not reliably identify or address problems with repositioning, care plans, medicines records and cleaning. The management team was working to improve oversight.
The latest report, explained

What inspectors found, January 2024

OSJCT Foxby Court was rated Requires Improvement; inspectors found risks with skin care, medicines, cleanliness and management oversight.

This was an unannounced focused inspection on 27 November 2023. Inspectors reviewed Safe and Well-led only. They spoke with people, relatives, managers and staff, observed care, and checked care records, risk assessments, medicines information and staff files.

The home was not always safe. Repositioning was not always recorded as needed, some care plans lacked important information, a medicines trolley was left unlocked and unattended, and some cleaning was not completed consistently. These issues created risks to people's safety.

Management checks had not identified or acted on several of these problems. The report says the new registered manager and head of care responded to the concerns and began making changes. Staff were caring, trained and understood safeguarding responsibilities.

The overall rating is Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other areas were not inspected during this visit, so their previous ratings were carried forward.

What inspectors praised

  • Safeguarding

    People told inspectors they felt safe. Staff understood their safeguarding duties and were confident that concerns would be acted on.

    “People were safeguarded from abuse and avoidable harm.” from the report

  • Staffing and recruitment

    The provider had established staffing levels and safe recruitment processes. Staff had appropriate training for their roles.

    “The provider ensured there were sufficient numbers of suitable staff.” from the report

  • Kind, person-centred support

    Staff supported people in the way they wished and showed good knowledge of their needs. Relatives described the culture as friendly and person centred.

    “The registered manager and staff worked to support people in the way they wished to be supported.” from the report

  • Openness

    The management team was described as open and inclusive. Relatives said they were involved in their family member's care.

    “There was a positive and open culture at the service.” from the report

  • Mental Capacity Act

    The provider was working in line with the Mental Capacity Act. People were supported to have choice and control where possible.

    “The provider was working in line with the Mental Capacity Act.” from the report
What inspectors were concerned about

  • Skin damage risks

    serious

    Some people were recorded as going between five and seven hours without repositioning at certain times. This put them at risk of skin damage.

    “Some people's repositioning charts showed at a particular time of day these people went for between 5 and 7 hours without being reposition.” from the report

  • Medicines safety

    serious

    A medicines trolley was left unlocked and unattended for about five minutes while mobile people were nearby. Records also showed that some topical creams had not been recorded as given.

    “We found a medicines trolley had been left in the dining room unlocked during our visit.” from the report

  • Care plan information

    needs fixing

    Some care plans did not give staff enough guidance about conditions such as Parkinson's disease and epilepsy, or about how to support known anxieties.

    “Some people who had underlying chronic health conditions such as Parkinson's or Epilepsy had no specific care plans about these conditions in their care records.” from the report

  • Cleaning and infection control

    needs fixing

    Some kitchen cleaning duties were not completed consistently. Rusted wheel casings on work trolleys could not be cleaned effectively.

    “Cleaning schedules in the kitchen showed some daily cleaning duties had not been undertaken consistently.” from the report

  • Management checks

    serious

    Quality audits had not identified or followed up several problems. This meant the home did not have reliable oversight of important areas of care.

    “This lack of oversight put people at risk of not receiving safe care and was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Questions to ask them, based on this report
  1. 01What changes have been made to ensure people are repositioned at the intervals in their care plans, and how is this checked?
  2. 02How do you now make sure medicines trolleys are locked and attended at all times?
  3. 03Which care plans have been updated for conditions such as Parkinson's disease and epilepsy, and how are staff told about the changes?
  4. 04How do you check that kitchen cleaning is completed and that equipment can be cleaned properly?
  5. 05What action has been completed in response to the Regulation 12 and Regulation 17 breaches, and what evidence can you show us?

This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 11 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of OSJCT Foxby Court

3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.

  1. January 2024Requires improvementcurrent ratingdown from Good
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at OSJCT Foxby Court →

  2. December 2017Goodstayed Good
    Safe: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. August 2015Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good

    Read this report on cqc.org.uk

  4. May 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  5. May 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. November 2010

    Registered with the Care Quality Commission on 16 November 2010.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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