Inspection on 11/07/06 for Footherley Hall

This inspection was carried out on 11th July 2006.

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

Footherley Hall 15/08/07

Footherley Hall 06/12/05

Footherley Hall 26/04/05

Footherley Hall 10/11/04

Footherley Hall 02/06/04

Footherley Hall 10/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Footherley Hall Footherley Lane Near Shenstone Lichfield Staffordshire WS14 0HG Lead Inspector Mrs Kathryn Marks Key Unannounced Inspection 11 July 2006 09:30 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 Footherley Hall DS0000004944.V302453.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. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Footherley Hall Address Footherley Lane Near Shenstone Lichfield Staffordshire WS14 0HG 01543 480253 01543 481548 manager.footherley@hsc-uk.org 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) Sisters Hospitallers of the Sacred Heart of Jesus Sister Maria Isobel Canton-Lopez Care Home 54 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (54), of places Physical disability over 65 years of age (5) Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Footherly Hall is 54-bedded Care Home for elderly people situated in the Village of Shenstone Nr Lichfield Staffordshire. The three-storey property is situated in attractive grounds with panoramic views from areas of the home. The home is currently subject to major refurbishment/extension work to upgrade and improve facilities. The registration category identifies that the home is registered to provide a service for individuals with a physical disability and dementia. The home is run by members of an order of sisters founded solely for the purpose of providing care with a positive ethos on religion of all denominations. Resident’s accommodation is provided on all floors, bedrooms are nicely decorated and designed to meet the needs and reflect the personality of the residents. Bathrooms and toilets are located throughout the home in close proximity to both communal areas and bedrooms. Grab rails, hoists, nurse call alarm systems and ramps were available around the home promoting residents independence. Spacious lounge and dining areas with views over the grounds and a conservatory providing a quiet area. Laundry facilities were provided, having staff appointed within this area to launder all clothing and linen for residents at the home. An impressive chapel was adjacent to the home providing an area for residents to practice their religious faith. Information gained from the Care Manager identified that the current fees charged are £375 to £430 per week. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Inspection was carried out on 11th July 2006 by two inspectors between 9.30 am and 3.15pm. Major refurbishment and extension work are taking place. The company health and safety officer was on site. During the course of the inspection many positive comments were received from residents via questionnaires and conversations with individuals. Residents spoken with told inspectors that they were well cared for by staff and comments included “the sisters are very kind to you” “I am very well cared for” “ the food is very good” the beds are comfortable” “I wish I had come before”. Visitors to the home said they were very happy with the care their relatives received at Footherly Hall. During the inspection information was seen regarding staffing, staff training, menu and care planning all were observed to be in place. On arrival at the home it was peaceful and relaxed residents had completed breakfast and were being assisted by staff to decide on daily routines. Each resident in turn was spoken to, asked if they required assistance and informed what was to happen. As at previous visits it was pleasing to see past reports easily available in the visitor’s room. Resident’s accommodation and the home generally were observed to be clean and maintained to a very high standard with resident’s personal space being individualised with favourite items. Two residents were case tracked care plans were reviewed, both residents were spoken with and their bedrooms visited. All residents have a full assessment of their needs carried out prior to admission to the home. Arrangements are in place for meeting the health and personal care needs of individuals with details recorded in care records that were sampled by the inspector. Regular social opportunities are available for individuals who wish to be involved. Residents are provided with a choice of well balanced meals prepared by qualified staff that talk to individuals about their dietary requirements and preferences. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 6 There is a complaints procedure at the home that service users when asked were aware of. This is given to individuals on admission and is contained in the service users guide and displayed in the home. Appropriate recruitment procedures were in place and all staff prior to employment has Criminal Records Bureau and Pova checks carried out. What the service does well: What has improved since the last inspection? All senior staff has completed computer training this still remains ongoing with more staff being involved. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 7 The requirement of the previous inspection has been met with staff having been trained in the Management of Medication (Carers Training Course Cannock College) Regular reviews of care plans takes place with the involvement of residents. 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. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 8 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 Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 9 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, 3, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service Users Guide provides prospective residents with details of the services Footherly Hall has to offer enabling an informed decision about admission to be made. Full assessment of residents needs is carried out. EVIDENCE: The homes Statement of Purpose and Service users Guide is given to residents and their relatives clearly describing the services and facilities Footherly Hall is able to offer. These documents will be updated to include the new facilities on completion of refurbishment work. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 10 As at previous visit prior to admission a full assessment of individual needs is carried out to ensure that Footherly Hall and its staff are able to meet the assessed needs of residents. Pre-admission visits are made to the prospective resident at home or in their current surroundings and holistic information is obtained and forms part of the assessment. The resident and/or their relative would where possible visit Footherly Hall to view the accommodation available. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents is well met. The systems for the administration of medication were observed by the inspector to be good, with clear arrangements being in place to ensure residents’ medication needs are met. EVIDENCE: As at the previous inspection all residents had in place an individual plan of care that is in modular form, large font and reviewed on a monthly basis. Risk assessments are in place and were included on care plan. Contacts regarding health and personal care issues are recorded in care records. District Nurse and General Practitioner confirmed that health care needs of residents are met. The General Practitioner holds a surgery at the home on a regular basis and attends on a call out in between. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 12 A sample of the medication taken on this inspection was located on the ground floor. No residents were self-medicating. Each individual record was identified with a photograph of the resident. Medication Administration sheets were examined and found to be up to date. The inspector identified that the staff responsible for medication had now received the appropriate training for the safe administration of medicines. Two residents were case tracked Health Care records, Care Plans, were reviewed bedrooms visited and residents spoken with. Throughout this visit staff were observed to be treating residents in a respectful way. The homes registered category includes 20 residents with dementia. It is strongly recommended that regular training updates take place for this diverse group of residents. Socialisation and activities for these residents should be evidenced via care plans and records. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and staff of the home provide a warm comfortable relaxed environment for vulnerable older people. Residents were encouraged to continue with their chosen life style. They were prepared a balanced diet with choices on a daily basis. Links with the community are good and support resident’s social opportunities. EVIDENCE: Residents at Footherly Hall experience a varied lifestyle with lots of activities taking place. During the inspection the inspector observed a number of the residents doing exercises, activities were planned for the majority after lunch when the staff had more time to spend with residents. This afternoon a general sing-a-long was taking place with residents and visitors, which they all seemed to enjoy. Visitors were full of praise for the home and its staff. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 14 Observations were made of residents exercising choice over whether they wished to be involved or not. Menus covered five weeks; the qualified cooks who were on duty throughout the day until 8pm prepared balanced nutritional food. The required food, fridge, freezer temperatures were maintained daily and evidenced in the records. Some residents have chosen to eat outside during the warmer weather protected by a pergola. Several residents go out regularly with relatives and currently one resident is in Ireland with her family for two weeks. Residents are looking forward to a BBQ at the end of August and the open garden day end of September. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system in place. EVIDENCE: As at the previous inspection the home has a complaints procedure that is displayed in the hallway at Footherley Hall; this is contained in the residents contract and explained to residents and their relatives on admission to the home. The procedure is detailed and explains how complaints are dealt with. There is a book at the home for recording of complaints and any action taken to deal with them this was seen at inspection and no complaints had been received since that inspection. Written information is provided to service users and their families for referring a complaint to the Commission for Social Care Inspection should they wish to? Staff training is carried out to protect individuals from abuse and is evidenced via training records. Observations of staff and relatives all assist in the protection of residents. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 16 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): 19,20,23,24,26. Quality in this outcome area is good. This judgement has been made using available evidence including a sample tour of the environment and visual observations. The ongoing building work has not prevented the staff from maintaining high standards of hygiene. Each of the bedrooms visited was personalised as individuals wished. Residents lived in a well-maintained environment; all efforts have been taken to ensure their safety during the major upgrade of facilities. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 17 EVIDENCE: Located in the countryside, Footherley Hall stands in attractive well-maintained grounds that staff and residents spend a lot of time in. Equipment was made available for any person requiring support with their daily living routine. Staff confirmed that they had received the appropriate training on the use of the hoists, and the new laundry washing machines and tumble dryers. A sample of the bedrooms on each floor identified that each resident was encouraged to personalise their room. Each one had individuality in colour and content. The management had provided the required furnishings and fittings. The management had made every effort to ensure that the residents were living in a safe environment during the major building work; where necessary staffs were observed to escort residents. Despite the major building work the staff maintained a very high standard of hygiene, residents live in a pleasant clean home. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service, speaking to the staff and reviewing the records. The provider continues to promote all the required obligatory training. The staff team on duty were observed to be competent, caring and respectful to all the residents. They demonstrated excellent care practices. EVIDENCE: The provider was part of the working team; an excellent team including the deputy care manager and senior supervisor supported her. Staffing levels vary from the morning shift when there would be thirteen staff plus management on duty. This reduced to seven staff plus management for the afternoon. Staffing levels were adequate to meet the needs of the residents. Ancillary staff on a daily basis total twelve staff each with their own role within the home. Staff training continued records provided information that the home had made bookings for external courses with Cannock College through until February 2007. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 19 There was a need for the provider to pursue current training in the care of people with dementia and to ensure that the training included stimulation and social care. Staff spoken with confirmed that they were up to date with their obligatory training and that they felt supported by the management. Staff were aware that more training was planned. From the records provided on the staff and recruitment the inspector identified that on the sample taken that not all the records had been collated. The manager needs to ensure that a copy of a persons birth certificate and current photograph was on the files. The home did have current photographs of all the staff displayed on a board in the main hall but not on the formal records. This will be addressed as a recommendation as all other documents were valid. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 20 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): 31,32,35,36,38. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service and discussions with a Health & Safety Consultant, staff observations and records. The home was operated in the best interest of the residents supported by robust training and by having an experienced staff team. Safety aspects for the residents were promoted with current fire records and procedures. EVIDENCE: Footherley Hall residents live in a home that is operated in the best interests for them to promote their chosen life style. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 21 The home has a very relaxed comfortable atmosphere promoted by the staff team. Records in respect of the small amount of resident’s finances were sampled and found to be accurate. There was a need for the staff responsible for formal supervision to ensure that records were maintained and planned within the timescale of six times a year. The records for the procedure and practice in the event of a fire were current. At the time of the inspection the manager was provided with a comprehensive detailed report from a Health & Safety Consultant. His role was as part of the building in progress and to monitor issues. He had identified in the report work to be undertaken and the time scale to which it was required. External to the new building a single rail fence had been erected this fence was at the top of a lawn that dropped away. This area was located at the edge of a patio to be used by the residents. The fence in its current condition does not blend in with the home and gave the inspector concerns as to the safety for the residents. It is a requirement that there be a more robust fence fitted. This area should not be used by residents until the safety has been addressed in some manner; unless the residents are fully supervised at all times. A full inspection of the electrics was planned for August 2007. The maintenance staff checked the water temperatures monthly; tests for legionella was planned as routine for the 17 July 2006. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 22 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 X 2 Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP38 Regulation 23(0) 13 (a) (c) Requirement It is requirement that there be a more robust fence with more horizontal rails fitted. Residents should not use this area until the safety has been addressed in some manner. Timescale for action 31/07/06 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 2 Refer to Standard OP12 OP29 Good Practice Recommendations Records are maintained for socialisation and activities for residents with dementia. For the person responsible to ensure that the records for each staff employed were accurate with all the required elements in Schedule 2. Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Extracts may not be used or reproduced without the express permission of CSCI Footherley Hall DS0000004944.V302453.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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