Inspection on 23/08/07 for Foley House

This inspection was carried out on 23rd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Foley House 15/09/06

Foley House 12/02/06

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 Neal Cranmer Key Unannounced Inspection 08.30 23 and 28th August 2007 rd 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.V349479.R01.S.doc Version 5.2 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.V349479.R01.S.doc Version 5.2 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 enquiries@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.V349479.R01.S.doc Version 5.2 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 15th September 2006 4. 5. Date of last inspection Brief Description of the Service: Foley House offers residential care to deaf and deaf/ blind adults. The premises have three floors and were 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 service users. The home is currently registered to cater for 5 day care service users. The basic fee range for staying in the home is £510.00, any further charge is then dependant upon the persons assessed needs. Additional charges are made for Hairdressing, Chiropody and newspapers. This information was provided by the registered manager during the visit to the service Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the service, which took place over two days in August 2007. The inspection lasted 9.00 hours in total. The inspection process included discussions with residents, staff and the registered manager of the home. To enable discussion with residents the inspector was accompanied during part of day one of the inspection, by Mr Walter Read a British Sign language Interpreter. In addition to the time spent in the home, the inspector reviewed written material submitted to the Commission since the last inspection in order to reach the conclusions identified in this report. This included five residents surveys, two relatives surveys and one visiting professionals survey. At the time of the visit to the home there were eighteen residents in residence at the home. On both days of the inspection the home was found to be clean and well maintained. The manager and her staff team were co-operative throughout the inspection, and the inspector was invited to have lunch in the home, and would wish to thank them for their hospitality. What the service does well: The home continues its commitment to ensuring that all staff are trained to British Sign Language level 1. Care plans continue to be of a high standard. Resident’s comments included, ‘Comfortable here at Foley House, food is beautiful… Relatives comments included, ‘ day-to-day care is provided in a pleasant and friendly way. ‘ The carers do a wonderful job…’ Arrangements for medical care sometimes lacks urgency. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 6 Visiting professional comments included,’ The management are often distant from the workforce and the resident’s’. 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. The summary of this inspection report can be made available in other formats on request. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 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.V349479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care and therefore Standard 6 is not relevant to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can expect their needs to be assessed prior to a service being provided, however the quality of the assessments can be variable. EVIDENCE: Three resident’s files were examined, two of which contained thorough assessments of need, which included detail of resident’s social, psychological and health needs, and which provided sufficient introductory information from which the home could determine whether they could met the needs identified. The third file sampled contained only limited information, which would be insufficient to enable a plan of care to be developed from the assessment information in it. The home does not provide intermediate care. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 9 Foley House DS0000017819.V349479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can expect their needs to be clearly set out in their plans of care, in a way that ensures they are treated respectfully, ensuring their dignity. They can further be assured that their healthcare needs will be included. Resident’s can be assured that the home’s policies and procedures for the administration of medicines is robust, and protects them well. EVIDENCE: The care plans sampled were of a good standard, there was evidence of input from resident’s, their families and representatives, the plans provided clear and detailed guidance to staff to enable them to meet the identified needs of the resident’s. The care plans continued to be well detailed with regard to resident’s physical and mental health and there was good evidence of there being systems in place to monitor resident’s health. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 11 The home’s medication administration practice was inspected, based upon the sample of records seen, the receipt, administration, storage, security and disposal of medication was found to meet with National Minimum Standards. The home operates a key worker system, and staff were aware of the role of the key worker, however discussion with resident’s indicated that they were not aware of the role, or who if anyone was their key worker, this was a comment repeated in the resident’s surveys returned. Discussion with resident’s through the British Sign language interpreter indicated that resident’s felt that their privacy and dignity was respected by staff. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can expect to be provided with a range of stimulating social and recreational activities, visiting arrangement at the home are open. Resident’s can expect to be provided with a balanced diet that is healthy and nutritious. EVIDENCE: The home currently employs one full-time activities co-ordinator, and plans were seen to be in place to appoint another member of staff to the same role on a part-time basis. On the day of the inspection preparation was in place at the time of the inspectors arrival for resident’s to be going out on a variety of day excursions. Just prior to the resident’s leaving for their daytime activities time was available for the inspector to speak to the activities co-ordinator who explained the type of activities provided in the home, these included in –house activities e.g. Bingo, Games, Cards, keep fit. Activities that take place externally to the home included: • Attending college Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 13 • Woodwork and gardening classes • RADD Lunch clubs • Shopping • Periodic visits to Southend • Attending Gateway club. The home does not operate a structured programme of activities, but records of activities that resident’s partake in are maintained. At the time of the visit preparations were underway to support eight residents on a weeks break to Norfolk. Resident’s surveys contained positive comments in respect of activities one comment said ‘I go to college and Gate way club every week, I enjoy that, lots of friends a Gateway and College’. Resident’s meetings continue to be held every Month and the minutes of these meetings evidenced that they are encouraged to voice their opinions about their lives in the home. The home operates a four weekly rotational menu, and those seen were balanced and varied. Food stocks sampled were good, and there was evidence of fresh fruit being available. Comments from resident’s shown in some of the surveys returned were very positive e.g. ‘The food here is beautiful’. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can be assured that the home has in place sound polices and procedures for dealing with complaints and allegations. EVIDENCE: The home has received two complaints since the last inspection, both were seen to have been recorded and logged, and investigated appropriately. The home has a complaints procedure that is made available to residents and visitors to the home. Comments from residents about how to complain were variable, some did not fully understand, whilst others clearly did. The home has an adult protection policy and procedure in place, which includes whistle blowing, providing a good level of information and guidance to staff for the to follow in the event of receiving an allegation of abuse. All staff had received training in adult protection. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can expect to be supported in an environment that is homely and well maintained. EVIDENCE: An environmental tour of the premises was undertaken in the company of the home’s assistant manager, the home was found to be clean and tidy and appeared to be well maintained, and there was no evidence of any unpleasant odours. The laundry was well organised, and there was evidence of some resident’s taking responsibility for doing their own laundry. The Home was seen to be well equipped, with specialist equipment to meet the needs of the resident’s e.g. Specialist baths, lifts, toilet seats, hand grab rails, Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 16 vibrating alert pillows and flashing alert lights in resident’s bedrooms to alert them when someone was at their bedroom door wishing to come in. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can expect to be supported by a team of staff who are competent, well lead and trained, they can further expect to be protected by the home’s robust recruitment practice. EVIDENCE: At the time of the inspection there were eighteen residents in residence in the home. The staff roster sampled over a four-week period indicated that there were three care staff on duty throughout the day; nighttimes were covered by two waking night staff. Additional catering, activity and domestic staff are employed in sufficient numbers. Staff were generally observed to engage positively with each individual and demonstrated a good relationship with the resident’s they were supporting, treating them with dignity and respect. However comments received in a number of the surveys returned spoke of staff being very busy and rushed particularly in the morning, one also spoke of some members of staff being quite rude. The recruitment files of four members of staff were sampled during the inspection, all of which contained the appropriate information and Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 18 documentation in respect of recruitment to promote the protection of resident’s from abuse. The home maintains a staff-training matrix, which indicated the training that each member of staff had undertaken, examination of this record showed that staff had received a lot of training, which included: • Infection control • First aid • Food hygiene • Health and safety • Manual handling • Fire safety. It was pleasing to the inspector to note that staff were now also being provided with training in meeting the needs of people with diverse needs. All staff with the exception of the newest recruits to the home are trained to level 1 in British Sign Language, and the home is in the process of putting forward further staff to undertake level 2. A substantial number of the care team hold National Vocational Qualifications in Care. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can expect to be supported in a home that is well managed and run in their best interests, where their views are sought, and policies are in place to protect their interests. EVIDENCE: The manager has a number of years of previous significant experience, and has a good relationship with the resident’s, and is aware of the development needs of her staff team. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 20 The providers are continuing to undertake their duty to monitor the home on a regular basis, and produce the reports required under Regulation 26 0f the Care Standards Act. The views of resident’s and other interested stakeholders are sought through the use of questionnaires, the survey for the year 2007 was provided, and evidenced that where negative responses had been received actions were taken to address the concerns identified. Other quality assurance processes used within the home included: Residents meetings held every month, Monthly monitoring visits by the registered provider. The home does manage the money of some of the residents, although they are supported and encouraged to maintain their independence as much as possible. The records sampled were well organised, and monies held were all in order. Staff are regularly formally supervised, and staff providing supervision to more junior colleagues have all received training for taking on this role. The home’s policies and procedures support the health and safety of resident’s and staff supporting them, and certificates relating to equipment and service to the home were in place and updated as required. Staff are all now receiving training in health and safety. Foley House DS0000017819.V349479.R01.S.doc Version 5.2 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 X x 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Foley House DS0000017819.V349479.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations The home should ensure that all pre admissions assessment forms are comprehensively completed and detailed. 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