Inspection on 12/02/06 for Foley House

This inspection was carried out on 12th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Foley House 23/08/07

Foley House 15/09/06

Foley House 13/07/05

Foley House 26/01/05

Foley House 09/07/04

Similar services:

Coopers Mill Ltd

Pocklington House

Newton Court (1-2)

Newton Court (3-4)

St Raphaels

Elkington House

Read House

Clacton Family Trust

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Foley House 115 High Garrett Braintree Essex CM7 5NU Lead Inspector Kay Mehrtens Final Announced Inspection 23rd February 2006 12:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Foley House Address 115 High Garrett Braintree Essex CM7 5NU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01376 326652 01376 326652 info@foleyhouse.org.uk Foley House Trust Mrs Brenda Weavers Care Home 20 Category(ies) of Dementia - over 65 years of age (1), Sensory registration, with number impairment (20), Sensory Impairment over 65 of places years of age (20) Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a sensory impairment (not to exceed 20 persons) Persons of either sex, aged 65 years and over, who require care by reason of a sensory impairment (not to exceed 20 persons) One person, aged 65 years and over, who requires care by reason of a sensory impairment and dementia, whose name was made known to the Commission in February 2006 The total number of service users accommodated must not exceed 20 persons No more than five persons may attend the home on a daily basis in addition to those 20 accommodated 13th July 2005 4. 5. Date of last inspection Brief Description of the Service: Foley House offers residential care to deaf and deaf/ blind adults. The premises has three floors and was originally built in 1881. Some areas of the home would not be easily accessible for those requiring the use of a wheelchair. The main building has seventeen rooms, most of which have ensuite facilities. There is a choice of several sitting areas and there is a separate dining room. In addition there is a purpose built unit providing modern facilities which comprises of four en-suite bedrooms, assisted bathroom, training kitchen, dining area and recreation room. This facility is also used for activities for the day care service users. The home is currently registered to cater for 5 day care service users. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Announced inspection which took place on the 23rd February 2006 lasting 5.5 hours. The inspection process included discussions with the manager and the deputy. The inspector was accompanied by a BSL interpreter, Dominic Berry, who assisted the inspector in a discussion group with six residents. There were sixteen residents accommodated at the time of the inspection. Samples of records and residents’ care plans were inspected. The inspector enjoyed the opportunity to meet with residents who chose to attend the discussion group over tea and cakes. This group questions were interpreted by the BSL interpreter and it was a very pleasant and informative meeting. The inspection covered ten standards relating to older people. This was the second statutory inspection of the year and focused on the remaining key standards not inspected at the last inspection, as well as a review of the requirements and recommendations from the last inspection. Two additional requirements were made to those not fully addressed from the last inspection. The home does accommodate younger adults and this inspection showed an improvement in the home’s meeting of the standards for younger adults. The inspector, as previously mentioned, had the opportunity to meet with service users that came under the standards for younger adults and their comments will be included within this report. The home’s manager, deputy and staff, have worked well since the last inspection to make positive improvements in the development of standards in relation to younger adults. The home was clean and well maintained. The manager and her staff team were very co-operative throughout the inspection. The inspector would like to thank the manager, staff team and residents for their hospitality and assistance throughout the inspection. What the service does well: The home is well equipped to meet the needs of residents with visual and hearing impairments. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 6 The feedback from the residents and relatives was generally positive regarding the care provided, particularly with regard to healthcare support. The residents spoke very highly of the new manager and felt that she had worked hard to meet their needs and make changes. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The arrangements for pre-admission assessments are good so staff are aware of residents’ needs prior to their placement. EVIDENCE: The manager had amended the home’s Statement of Purpose and it now reflects all aspects of care provided at the home. The care files sampled showed that detailed assessments were done by the deputy and senior care staff for all pre-admission assessments. Those seen covered the personal and healthcare needs of prospective residents with information gathered from the residents and their families. The assessments were detailed and well written particularly with regard to the sensory requirements of residents. Information gathered from the assessment was used effectively to form detailed care plans that covered all identified needs. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 9 Daily recording on care notes was written in regular intervals by staff throughout the day and contained relevant and detailed references to residents’ emotional, physical and healthcare needs. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 and 10 The health care needs of residents were well met. The manager and staff are caring and positive in their contact with residents. EVIDENCE: Residents and their families were pleased with the healthcare provided at the home. The manager and staff showed a good understanding and awareness of individual residents’ needs. They were able to inform the inspector of specialist appointments and input for different residents and were positive in their attitude and approach towards meeting the residents’ needs and contacts with healthcare professionals. One of the doctors for the home responded to the Commission’s survey and was very positive in their comments regarding the healthcare provision at the home. They were clear that they could see their patients in private and were kept informed of matters that affected their healthcare. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 11 Residents spoken to at the meeting with the interpreter were clear that their healthcare needs are met and that they could talk to staff regarding any issues and difficulties. They said that they were involved in their care planning and felt well supported by staff when meeting doctors. As previously stated, residents in the meeting spoke confidentially and positively regarding the staff respecting their rights to privacy and their confidentiality. They told the inspector that staff would press the “flashing doorbells” on their bedrooms before entering. Some residents did say that some staff just came in to check them at night and they would rather they didn’t. They were happy for the inspector to share this with the manager so that their choice not to be disturbed at night would be respected. Some residents, in the meeting, also commented about car lights, (possibly from night staff), lighting up their bedrooms through curtains that were not always fully drawn and were again happy for this to be raised with the manager so that this could be addressed. It was very clear, from the residents comments, that they felt able to share issues with the manager and staff and were happy for the inspector to put forward some of their comments raised at the meeting during the inspection. The residents told the inspector that they can meet their friends at their home in private and that they have access to plenty of space and rooms to talk and meet with relatives, friends and doctors in private. The residents felt that the staff were generally very respectful although they felt at times some staff were in a hurry. One resident did comment about a member of staff who they felt hurried them, especially when assisting with their bath and hair wash. This was brought to the attention of the manager. The residents told the inspector that they felt they had a good relationship with the manager and that she listened to them. They also felt they were able to talk to the staff as most of them were now learning to sign BSL and they were pleased with this. They felt that the communication with staff had improved because of this training. they also said that even though the manager’s signing is not good, she is a good communicator and listens to them. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Opportunities for residents to participate in activities in the home and the local community have improved. Residents are supported in maintaining contact with family. Residents’ choice is respected in many aspects of their life in the home. Catering arrangements are good. EVIDENCE: The residents told the inspector they enjoyed the meeting with the inspector and interpreter and certainly used it to share their comments and feelings about many aspects of their life in the home. This included positive comments about the support provided by the manager and staff in accessing and maintaining contact with their family and friends. They said that they felt their home was relaxed and friendly and they enjoyed going out to local clubs and facilities. Residents told the inspector that activities had improved since the last inspection as the home had a new activity worker. They still siad that there were very few activities in the morning and they tended to sit and not do very Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 13 much as staff were generally busy with breakfast and personal care for other residents. However, they had enjoyed recent outings and had used residents meetings to share ideas for future events in the home and in the locality. The minutes, from the residents meetings, verified comments about various activities including holidays, access to the home’s beach hut, coffee mornings with friends from local clubs, gardening club and fete, as well as other activities. The residents were clear that their choice is respected in every aspect of their life within the home. They felt that they were able to come and go as they pleased and that staff supported them in their personal wishes and needs around such areas as bedtimes, meal times and activities. The residents told the inspector that they felt more involved in aspects of their life in the home since the last inspection and referred particularly to the choice of bedroom colours and attending meetings. Some did say that they would like to go out more and also felt a working computer in the home would be helpful. They were happy for these issues to be raised with the manager and this was done during the inspection. The manager and cook seek the residents’ comments about meals and the menus. The residents were very complimentary about the meals provided. They said that they enjoyed the different meals and home cooked food provided by the new cook. Residents were offered a very good choice of food, on the day of the inspection, and care plans seen indicated personal preference and dietary needs. Several relatives returned the questionnaire from the Commission and the majority were very complimentary regarding the care provided in the home. One relative stated that “the carers at Foley House – in my experience are friendly, efficient and do their best to make the residents comfortable – well done !” Another relative commented on the change of manager and staff but was generally complimentary regarding the staffing levels and care provided by the home. Those residents that were unable to attend the meeting with the interpreter were spoken to by the inspector and were also given the opportunity to complete a service user comment card. Their comments were very positive regarding the care provided and the support given to them by staff with regard to their personal and social needs. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected at this inspection. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Residents are provided with a safe, well maintained and pleasant home. EVIDENCE: The home is well equipped to meet the needs of service users with physical, hearing and visual impairment. The home is large, space, bright and well maintained. The residents have access to a large patio area and pleasant garden space. There are ample parking facilities for visitors to the home. The entrance to the home is secure and residents are encouraged to sign in and out to assist with fire procedures. The tour of the premises showed that the stair lift was broken and the manager informed the inspector that repairs were planned. She also stated that there was a plan to do large repairs on the shaft lift which would take up to two weeks to complete. The inspector advised her to write to the Commission, detailing a plan for the repair and alternative accommodation for Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 16 residents on the first floor during this process. Alternative rooms on the ground floor were seen at the inspection and considered suitable for short term bedroom space during the lift repairs. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Staff recruitment practices are sufficient to ensure residents’ protection. Staffing levels and training ensure that the needs of the residents are well met. EVIDENCE: Examination of the staff rota and observation during the inspection, showed that staffing levels are sufficient to meet the needs of the current resident group. There are three staff on duty throughout the waking day, with two awake night staff on duty. In addition, the manager is available during the week as is her deputy. There are sufficient domestic and catering staff employed. The home also employs an activity worker who works flexible hours with an additional activity worker for two days per week. The staff were observed to be polite and respectful when in the company of the residents. The staff were also observed to use signing when with residents and responded appropriately to requests for assistance. The staff recruitment records are well organised. The requirement raised at the previous inspection had been addressed and all appropriate checks and information had been gathered and signed on each file. The commitment to staff training has improved under the new manager. Staff files were well organised and the deputy manager had produced a programme Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 18 for training that highlighted staff needs, development, achievements and requirements for refresher training. As previously mentioned in this report, many staff are undertaking British Sign Language Stage 1 and 2 and residents have seen this as beneficial and helpful to them. Records also indicated ongoing training with regard to first aid and fire. However, it was noted that several members of staff required updates with regard to manual handling. Information received, as part of the pre-inspection questionnaire from the manager, showed that ten members of staff had achieved NVQ Level 2, which is approximately 70 of staff now qualified so this standard is well met. Records also showed that several members of the night staff both domestic and catering staff are undertaking sign language training, this is to be commended. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 38 The management style is very much focussed on the best interests and needs of the residents. Practices and procedures ensure that the health and safety of residents are protected. EVIDENCE: The manager and her deputy showed a good understanding and awareness of the needs of the resident group. Responses to surveys and questionnaires and from discussions with residents indicate that the manager is well thought of by residents, their families and professionals. The manager had undertaken a Quality Assurance Survey. She had gathered information from residents, staff, families, friends, specialist healthcare teams and Social Services. The responses and outcomes from the survey were Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 20 incorporated into a written document, produced in large print for residents. This is a standard that the manager and her staff team have worked well on and moved forward on since the last inspection. The inspector advised the manager to produce an action plan, based on the outcomes following the Quality Assurance Survey, that incorporated resident involvement. The manager informed the inspector that she was aware of the need to develop residents’ involvement in quality assurance and other areas of policy in the home. She also stated that certain residents had, more recently, been involved in policy reviews that looked at activities and house routines. The inspector had noted and was impressed by the development, by the manager and staff, to involve the residents more in the running of their home and in more age appropriate activities, which develop their independence. The residents spoken to appreciated this development and the inspector will continue to monitor development at each inspection. Health and Safety records were well organised. The required checks with regard to electrics, gas and water temperatures were maintained and monitored. The manager and her deputy were very aware of the need to ensure the required regulations for health and safety are implemented. The manager had carried out a fire risk audit. However, examination of the fire records indicated that further fire drills were required, particularly for night staff. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16 Requirement Timescale for action 24/05/06 2 OP30 13 3 OP33 24 4 OP38 23 The registered person must ensure that there are a variety of activities that reflect service users’ choices. This is a repeat requirement, which will be monitored as the inspector noted improvements in the home towards meeting this standard. The registered person must 24/05/06 ensure that all staff receive training with regard to manual handling. The registered person must 24/05/06 ensure that a regular review of the quality of care is done and an action plan, with input from service users, is achieved following the review. The registered person must 24/05/06 ensure that all staff undertake regular fire drills. Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Foley House DS0000017819.V277839.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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