Inspection on 15/08/07 for Footherley Hall

This inspection was carried out on 15th 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

Footherley Hall 11/07/06

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 15th August 2007 09:00 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.V342197.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.V342197.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 Tomasa de la Torre 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.V342197.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2006 Brief Description of the Service: Footherly Hall is a 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. The accommodation of people who use the service is provided on all floors, bedrooms are nicely decorated and designed to meet the needs and reflect the personality of the Individual. 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 the independence of people who use the service. 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 individuals at the home. An impressive chapel was adjacent to the home providing an area for people who use the service to practice their religious faith. Information gained from the Care Manager identified that the current fees charged are £395 to £500 per week. Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced Inspection was carried out on 15th August 2007 by one inspector between 9.30 am and 5.15pm. Major refurbishment and extension work that has been taking place at the home is now almost complete. During the course of the inspection today positive comments were received from people who use the service both verbally and via questionnaires and conversations with relatives. People who use the service spoken with told the inspector that they were well cared for by staff and comments included “the sisters and staff are kind to you” “I am very well cared for” “ the food is very good and if you want something not on the menu you can have it” “my bedroom is 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. People who use the service and relatives confirmed this in questionnaires. During discussions with the care manager information was seen regarding staffing, staff training, menu and care planning. As at previous inspection on arrival at the home it was peaceful and relaxed people who use the service had completed breakfast and were being assisted by staff to decide on daily routines. The accommodations of people who use the service and the home generally were observed to be clean and maintained to a very high standard with personal space being individualised with favourite items. Four people who use the service were case tracked care plans were reviewed, individuals were spoken with and their bedrooms visited. All people who use the service 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. People who use the service are provided with a choice of well balanced meals prepared by qualified staff that talk to individuals about their dietary requirements and preferences. 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: Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 6 The home continues to provide a high standard of care and facilities. Relatives said that the ambiance created for people who use the service was very reassuring for families. The home presents as a nice friendly atmosphere refurbishment has provided a high standard of accommodation for people who use the service. The sisters and care staff at the home are helpful and individuals spoken with said they find them approachable. Regular staff training takes place with individual training needs being reviewed on a regular basis and identified on training matrix. What has improved since the last inspection? What they could do better: Feedback from people who use the service and relatives generally said “more staff to facilitate more outings” Care plans to be consolidated into one folder to bring all areas together. Need to record in more detail socialisation and activities for people who use the service who have dementia. Where receipts are building up in the purses of people who use the service these receipts should be filed away for safety. The responsible individual/care manager should maintain contact with central registration team with regard to registering new rooms and extension. Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 7 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. Footherley Hall DS0000004944.V342197.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.V342197.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: 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 people who use the service. Pre-admission visits are made to the prospective people who are to use the service at home or in their current surroundings and holistic information is obtained and forms part of the assessment. The individual and/or their relative would where possible visit Footherly Hall to view the accommodation available. Outcome of assessment is confirmed to service user and relative in writing. Footherley Hall DS0000004944.V342197.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): Standards 7,8,9,10 were reviewed at this visit. 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 people who use the service 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 individuals medication needs are met. EVIDENCE: As at the previous inspection all people who use the service had in place an individual plan of care that is 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. Care plans are detailed and provide lots of information they are currently being brought together to provide one file in a modular format. The General Practitioner holds a surgery at the home on a regular basis and attends on a call out in between. Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 11 A sample of the medication taken on this inspection was located on the 1st Floor medication administration sheets were examined and found to be up to date. As at previous inspection no individuals were self-medicating. Each individual record was identified with a photograph of the people who use the service. The inspector identified that the staff responsible for management of medication had received the appropriate training. All senior staff is doing extra five units in management of medication at Cannock College. Six members of staff are now doing a Dementia training course at Cannock College. Staff are also doing training course Activities/Socialisation to ensure diverse needs are met. Four people who use the service were case tracked Health Care records, Care Plans, were reviewed bedrooms visited and individuals spoken with. Throughout this visit staff were observed to be treating people who use the service in a respectful way with privacy and dignity being promoted. Footherley Hall DS0000004944.V342197.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): Standards 12,13,14,15 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle and are supported to do so ensuring that recreational and cultural activities meet individual’s expectations. EVIDENCE: Records are maintained of various activities that take place. On completion of the 1st floor extension people who use the service who have dementia will be moving to this floor and a separate activities programme will commence for individuals with short concentration span. Currently all are involved in same activities. Community contact is maintained a lot of visitors in and out of the home there is a BBQ arranged for Sunday lunchtime. Church services are held in the homes chapel; every six weeks an external entertainer visits the home. Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 13 A fulltime activities co-ordinator is employed 10am to 5pm Monday to Friday takes all people who use the service and does something with everyone. People who use the service where able go out with relatives out to garden centre with staff or place of individual’s choice monthly. Observations were made throughout this inspection of people who use the service making choices with flexible routines in place. The home has in place a five-week rotating menu that offers wholesome traditional food that people who use the service said they enjoyed. Lunch today was nicely presented and portions were generous. Footherley Hall DS0000004944.V342197.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): Standards 16,18 were reviewed at this visit. 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 procedure in place ensuring that people who use the service are able to express their concerns, are protected from abuse, and have their rights protected. 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 contract of people who use the service and explained to individuals 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 contained two minor grumbles that had been dealt with satisfactorily. Written information is provided to people who use the service and their families for referring a complaint to the Commission for Social Care Inspection should they wish to? Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 15 Staff training is carried out to protect individuals from abuse and is evidenced via training records. Staff have received Vulnerable Adults training, stress management training, challenging behaviour and elder abuse. Observations of staff and relatives all assist in the protection of people who use the service. Footherley Hall DS0000004944.V342197.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building work and upgrade of the home has not prevented the staff from maintaining a high standard ensuring a safe clean environment for people who use the service to live in. EVIDENCE: As at the previous visit located in the countryside, Footherley Hall stands in attractive well-maintained grounds that staff and people who use the service 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 to use equipment. Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 17 A sample of the bedrooms on each floor identified that people who use the service was encouraged to personalise their room. Each one had been individualised in colour and content. The management continue to make every effort to ensure that the people who use the service were living in a safe environment during the major building /refurbishment work. Despite the building work the staff maintained a very high standard of hygiene, people who use the service live in a pleasant clean home. Footherley Hall DS0000004944.V342197.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of staff in the home are trained and sufficient in numbers to support people who use the service, in line with their terms and conditions, and to support the smooth running of the home. EVIDENCE: As at the previous visit the registered care manager was part of the working team; team included the deputy care manager and senior supervisor supporting 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 observed needs of the people who use the service. Ancillary staff on a daily basis total twelve staff each with their own identified role within the home. Staff training continues records being maintained. Records identified mandatory training had been carried out and staffs were aware that more training was planned on an ongoing basis. Appropriate recruitment procedures are in place prior to employment Criminal Records Bureau checks and Protection of Vulnerable Adults checks are carried out. Two written references are obtained. Footherley Hall DS0000004944.V342197.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): Standards 31,33,35,38 were reviewed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems. The Care Manager is well supported by her line manager ensuring the health and welfare of people who use the service is observed. Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 20 EVIDENCE: Footherley Hall residents live in a home that is operated in the best interests for them to promote their chosen life style. The Care Manager is registered RMN/RN she has the Registered Managers Award NCFE L2 Safe Handling of Medicines, certificate in OH and Safety, D32/33 NVQ Assessors award. She has been in post at Footherly Hall since January 2007 and has worked in care of the elderly for many years. The home has a very relaxed comfortable atmosphere promoted by the staff team. Records in respect of finances of people who use the service were sampled and found to be accurate. Receipts should be safely filed. The health Safety and Welfare of people who use the service and staff are promoted with safe working practices being promoted. Footherley Hall DS0000004944.V342197.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 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 X X X X X X 3 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 X 3 X 3 X X 3 Footherley Hall DS0000004944.V342197.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 OP12 Good Practice Recommendations Records are maintained for socialisation and activities for residents with dementia. Footherley Hall DS0000004944.V342197.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor, Ladywood House 45-46 Stephenson Street BIRMINGHAM B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V342197.R01.S.doc Version 5.2 Page 24 - 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. 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