Inspection on 26/04/05 for Footherley Hall

This inspection was carried out on 26th April 2005.

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 11/07/06

Footherley Hall 06/12/05

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 Kathryn Marks Unanounced 26 April 2005 10:00 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 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 E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Footherley Hall Address Footherley Lane Near Shenstone Lichfield Staffordshire ST14 OHG 01543 480253 01543 481458 Telephone number Fax number Email 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 Isabella Canton Care Home 54 Category(ies) of 54 OP registration, with number 5 PD(E) of places 20 DE(E) Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 10 November 2004 Brief Description of the Service: Footherly Hall is 54 bedded Care Home for elderly people situated in the Village of Shenstone Staffordshire. The three storey property is situated in attractive grounds with panoramic views from areas of the home. 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. Residents accommodation is provided on all floors, bedrooms are nicely decorated and designed to meet the needs and reflect the personality of the resident. 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. Residents from other religious denominations were supported and enabled to continue to practice their identified relitualpath. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day on the 26th April 2005. During the course of the inspection Inspectors received many positive comments from residents, and relatives visiting the home also the visiting district nurses. The district nurse said that the team experienced very good relationships with the home, that diabetic care and pressure care were excellent that the sisters were very caring. During the inspection written 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 very busy residents were completing breakfast and staff training was taking place for both day staff and night staff. It was pleasing to see past reports easily available in the visitors room. Individual residents were moving freely in/out and around the home as were their visitors. 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. 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. 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/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 checks carried out. The Inspector saw evidence of this at the time of inspection. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 6 What the service does well: 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. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 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 standard(s) 3, standard 6 is not applicable to this home. The home has in place detailed assessment procedures that are implemented prior to the admission of residents to the home. EVIDENCE: Prior to a bed being offered to a prospective resident a visit is arranged to Footherley Hall for the individual and or their relative. Inspector saw both a formal assessment form that gathers holistic information and admission to/from hospital form. Sisters also carry out a pre admission visit to the individual in their own home or current surroundings. Following these assessments a letter confirming the outcome of the assessment is sent to the individual to inform them of whether the home can or cannot meet their needs. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,9,10,11. Appropriate arrangements are in place for identifying and meeting the health and personal care needs of residents in the home. Recorded information is detailed. EVIDENCE: All residents had in place an individual plan of care that is in modular form, these care plans are currently being reformatted to make them easier to read. General practitioner details were out of date for one resident and need to be updated. Risk assessments are in place and were included on care plan. Contacts regarding health and personal care issues are recorded in care records. Lockable facility has now been provided in all bedrooms so individuals that may choose to self medicate have secure storage facility. Residents consulted said that staff and the sisters treat them in a respectful and dignified manner at all times. The home as in place policies and procedures for death and the dying that is discussed with service users and families at the time of producing the care plan. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12,13,14,15. Management and staff of the home provide a warm comfortable relaxed environment for vulnerable older people. Links with the community are good and support and enrich resident’s social opportunities. EVIDENCE: Residents at the home experienced a relaxed comfortable lifestyle with social opportunities being available for individuals who wished to be involved. Flexible routines were in place with individuals choosing what they wished to do. Residents were able to receive religious services this was observed when some residents took Holy Communion. The majority of residents were spoken with by inspectors one resident told an inspector you could never be lonely here. Two residents confirmed that they were to go out for afternoon tea at the local garden centre as part of the winning prize for the Easter bonnets. Everyone at the home is involved in preparing for the annual fete on the 9th July. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 11 A full programme of forthcoming planned activities was displayed in the entrance. Residents confirmed to the Inspector that they had a choice over their life styles and felt that they could approach any of the staff or management in the event that they had a problem. They were positive that any concerns would be dealt with. One visitor spoken with told the inspector she felt welcome every time she visited the home, this welcome was extended from the reception staff throughout the home. There are three cooks employed over a period of seven days. Their day commenced early morning and continued until suppertime. The meal of the day was prepared fresh each day. Observations were made in the storage area of plenty of fresh fruit and vegetables. The required temperatures were current and made available to inspector. Dietary needs were catered for; the catering staff would obtain information on an alternative diet prior to serving. Within the kitchen is a new fast chiller this equipment ensured that food is cooled within the required time span. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16,17,18, The home has a satisfactory complaints system in place with some evidence that service users feel that their views are listened to and acted upon. EVIDENCE: 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. 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. A training update is due to be held on Elder Abuse. Observations by staff and relatives when in the home all assist in the protection of residents. Staff spoken to were aware of issues surrounding abuse and were able to identify areas where abuse could occur. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,20,21,22,23,24,25,26. The standard of the environment within this home is good providing residents with an attractive and homely place to live. Residents have sufficient space to enable them to live comfortably. EVIDENCE: Located in a quiet lane near the Village of Shenstone Footherly Hall provides care for vulnerable older people. Bedrooms were located on three floors accessed by a new 13-person shaft lift recently installed. Observations of bedrooms visited indicated that residents are encouraged to bring in personal items to individualise their own space. The home has an ongoing refurbishment programme for bedrooms. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 14 Bathrooms and toilets are located throughout the home adjacent to both communal and bedroom areas. An occasional terry towel was observed, this was discussed at feedback with the management who will address the issue. Following discussion there were plans to erect a small cupboard in the toilets to contain extra toilet rolls. Externally gardens are very attractive a lot of work by management has gone into the planning and development of the grounds and this is much appreciated by residents. Footherly Hall is very well maintained to a high standard both in décor and hygiene. The Commission have received plans for extensive work within the Hall, which will further enhance the quality of lifestyle for the residents. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. The home has in place robust procedures for the recruitment of staff. At the time of this inspection staff on duty were satisfactory in number to meet the observed needs of individuals in their care. EVIDENCE: The examination of rotas and discussions with the registered manager confirmed that adequate staffing hours were provided to meet the needs of residents on a twenty-four hour basis. The staff on duty was twelve care assistants in the morning, six care assistants in the afternoon, assistant officer, deputy officer, and five sisters. Staff who are experienced were observed to be aware of the needs of service users in their care. Staff training records is maintained and identified training carried out, and what training needs to be put in place. There are fifteen staff with NVQ Level 2 and eleven staff with NVQ Level 3. Policies and procedures are in place for recruitment of staff with appropriate procedures being followed. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,38. The management ensured that as far as is reasonably practicable the health safety and welfare of the residents and staff were protected. Observations were that residents are consulted and informed about what is happening in the home. The manager is accessible to residents and staff and staff said they could talk to management. Records examined were detailed and up to date. EVIDENCE: Residents said they were informed about what is happening in the home and positive interaction was observed between management staff and residents. Residents now have security boxes fitted in their bedrooms and relatives and families are to manage finances. The home will manage finances for five residents whose relatives live away from the area. Two residents had advocates. Residents finances sampled balanced with records maintained. The management delegated the responsibility of the weekly/monthly testing of the fire systems records were well maintained. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 17 Management had a robust training programme in place evidenced during the inspection was the third session of First Aid training; this ensured that all the staff will have received training. Staff confirmed that they will be signing up for NVQ in care in the very near future and were looking forward to the challenge. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 x 3 x x 3 Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 19 Are there any outstanding requirements from the last inspection? 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 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 7 Good Practice Recommendations Audit of residents general practitioners details should be carried out to ensure the correct general practitioner is identified on care records. Footherley Hall E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Stafford - 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 E51-E09 S4944 Footherley Hall V222731 260405 Stage 4.doc Version 1.30 Page 21 - 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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