Inspection on 06/12/05 for Footherley Hall

This inspection was carried out on 6th December 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 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 Unannounced Inspection 6th December 2005 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.V271666.R01.S.doc Version 5.0 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.V271666.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Footherley Hall Address Footherley Lane Near Shenstone Lichfield Staffordshire WS14 0HG 01543 480253 01543 481548 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.V271666.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 2005 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. Resident’s 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. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection over half a day on the 6th December 2005. During the course of the inspection Inspectors received many positive comments from residents. Residents spoken with told inspectors that they were well cared for by staff and comments included “you are very kind to me” “I am very well cared for” “ the food is very good”. 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. Staff interacted in a relaxed manner with the residents. 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. 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. Observations were made of two residents being taken to their bedrooms to wait for their GP to visit them. 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. 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. A planned refurbishment of the home is due to start with work currently taking place on the car park and a new entrance. What the service does well: Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 6 The homes Statement of Purpose and Service Users Guide provides prospective residents with details of the services the home has to offer enabling an informed decision about admission to be made. As at the previous inspection residents are cared for in a warm caring environment where individuals are consulted about ongoing care and their specific needs. Regular staff training takes place with individual training needs being addressed and records maintained. On arrival there was a relaxed tranquil atmosphere in the home with positive exchanges being observed between staff and residents. 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 DS0000004944.V271666.R01.S.doc Version 5.0 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 Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. 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. 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. All residents have a contract of their terms and conditions of residence at the home that is explained/discussed with the resident and their relative. 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 the prospective resident. 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.V271666.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10. Because of the lack of appropriate recognised training for the management of medication the staff are vulnerable to errors. There needs to be awareness for the staff responsible of the importance for up to date and detailed administration, storage and recording of medication. EVIDENCE: 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. A sample of the medication taken on this inspection was located on the second floor. Each individual record was identified with a photograph of the resident. The inspector had concerns in respect of the recording for medication administered. Identified were a number of “gaps” where the staff responsible had not signed the record. This included one resident who was prescribed Warfarin. Two separate eye medications while stored appropriately were not dated to confirm when they were opened. A tube of Hydrocortisone cream was left in a box without a cap; the box and prescribed name did not correspond. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 10 One resident had been given on instruction of a senior member of the management medication to assist with constipation. This particular resident was not prescribed this form of medication. Medication should not be used for any other resident than the person to which it is prescribed. The inspector identified that the staff responsible for medication had not received the appropriate training for the safe administration of medicines. These concerns were fully discussed with the registered Care Manager and Head of Care at feedback. The home has 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. Three residents were case tracked Health Care records, Care Plans, were reviewed bedrooms visited and residents spoken with. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 11 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. 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 and enrich resident’s social opportunities. EVIDENCE: During the inspection the inspector observed a number of the residents playing Bingo, activities were planned for the majority after lunch when the staff had more time to spend with residents. Records evidenced that residents were involved in simple craft, planting bulbs in pots, exercises and music. Special days in the year were celebrated. Arrangements were in place for the residents Christmas party. 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. The kitchen area was part of the major refurbishment planned for the home. The cook on duty was pleased with the purchase of a new blast chiller, which ensured that food was cooled within the required time. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 12 During the inspection and discussions with the cook and management it was agreed that opaque boxes would be purchased for the kitchenettes to store food in the fridges, these boxes would have an additional label identifying when the food was stored. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 13 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): 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: 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. 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. Staff the inspector spoke to were aware of issues surrounding abuse and were able to identify areas where abuse could occur. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 14 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): 20, 21, 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. The home is due to start a refurbishment project to improve facilities for everyone. EVIDENCE: A general overview of the building was undertaken, the high standards were a credit to the staff responsible. Bedrooms were personalised by individuals. Bedroom 67, which was identified to the care manager, required the door to be adjusted to ensure that it closed effectively in the event of a fire. The main lounge carpet would benefit in parts to be re-stretched to ensure the safety of the residents and staff. Current temperatures were maintained for the water accessed by the residents. The laundry staff confirmed that their COSHH and Health & Safety working with equipment were current. The laundry area will be the first to be re-located as part of the major planned refurbishment. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 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 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. 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 Deputy Manager confirmed that adequate staffing hours were provided to meet the needs of residents in the home. Staff on duty was ten care assistants in the morning, six care assistants in the afternoon, assistant officer, deputy officer, and four sisters. Housekeeping staff one cook, one kitchen assistant, four cleaners, two laundry persons, four garden/maintenance and the hairdresser. Staff on duty was 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 is fifteen staff with NVQ Level 2 and eleven staff with NVQ Level 3 NVQ training is ongoing for all levels. Policies and procedures are in place for recruitment of staff with appropriate procedures being followed. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 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 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): 31,32,33,34,35,36,37,38. 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. The home manages finances for five residents whose relatives live away from the area. Two residents had advocates. Residents finances sampled balanced with records maintained. During the inspection staff spoken with, confirmed that they received regular supervision sessions that explored their training /development needs. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 17 The management delegated the responsibility of the weekly/monthly testing of the fire systems. Observations of records evidenced that the persons responsible for the procedure and practice of protecting residents and staff in the event of a fire had maintained records satisfactorily and up to date. It was suggested to one of the persons, that via a list of the staff employed he could ensure that each member of the staff had received the appropriate fire drill awareness. This was discussed and agreed with the care manager at the feedback. Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X 3 3 X 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 3 3 3 3 3 3 3 3 Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation Requirement Timescale for action 31/12/05 13 (2) & The person responsible shall 18 ( c ) (i) make arrangements for the appropriate recording and dating of medication received into the care home. The person responsible shall ensure that persons employed at the home receive training appropriate to the work they are to perform. 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 OP38 Good Practice Recommendations The person responsible for the procedure and practice of fire protection to have a current list of staff ensuring that all staff had been involved in a fire drill in 2005 Footherley Hall DS0000004944.V271666.R01.S.doc Version 5.0 Page 20 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.V271666.R01.S.doc Version 5.0 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. 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