Inspection on 10/05/06 for Foxby Court

This inspection was carried out on 10th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Foxby Court 28/11/05

Foxby Court 24/06/05

Foxby Court 30/11/04

Foxby Court 21/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Foxby Court Middlefield Lane Gainsborough Lincs DN21 1QR Lead Inspector Mr Doug Tunmore Key Unannounced Inspection 10th May 2006 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 Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Foxby Court Address Middlefield Lane Gainsborough Lincs DN21 1QR 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) 01427 613376 The Orders Of St John Care Trust Mrs Melanie Killelay Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Foxby Court is one of a group of homes run by the Order of St John Trust (OSJT). It is purpose built with all accommodation and services being on the ground floor. All rooms are currently single, with en-suite washing and toilet facilities. There are five different lounges and a large dining room. The home is situated in the south east of Gainsborough, on the edge of a residential area in large well-maintained grounds and gardens. Car parking is to the front of the building and there is a bus stop close by which residents and relatives can use to go to town or visit this home. Transport and support is provided to those residents who require it by the Trust. The stated aim of Foxby Court is to provide residents with a secure, relaxed and homely environment in which their care, wellbeing and comfort are of prime importance. The current scale of charges at this home starts at £335.00 to £415.00 per week. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took any previous information held by CSC including the homes previous inspection reports, their service history, the homes pre-inspection questionnaire and residents questionnaires sent to the home by the Commission prior to this inspection all of which was taken into account. The site inspection consisted of case tracking a sample of the resident’s records and assessing their care. The inspector spoke with two residents who were being case tracked two who the inspector joined for lunch, two visitors, one member of staff, the cook, administrator as well as the activities organiser. The inspector also spent time with the registered manager. A partial tour of the home and a review of a sample of the records was also included. What the service does well: What has improved since the last inspection? The home has taken action to address one requirement and one recommendation raised at the last inspection. The home has given all carers The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes long-term needs assessment records identify residents preferences regarding activities and outings as well as everyday choices regarding their daily living requirements. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 6 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. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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 Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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): 2,3 & 6 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted into the home only after a full needs assessment has been carried out either by the home and or health care or social care agencies. Written confirmation that the home can meet a prospective residents needs is also undertaken prior to admission. This home does not provide intermediate care. EVIDENCE: A review of all information available prior to this inspection and evidence seen at this inspection in residents files and care plans showed that the home does not admit residents without a care assessment being undertaken. Prospective residents are also written to by the home confirming that they can meet the residents care needs or not. Two residents confirmed that they had been visited by the home prior to admission and had also visited the home either with a relative or a social worker. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 9 Questionnaires returned to The Commission show that thirty-one of the thirty two received from residents confirmed that they had information about the home prior to admission. However, ten residents had omitted to comment or were unaware that they had received a contract. The homes administrator evidenced in the residents finance files that those residents who were being case tracked had current contracts. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents or their representatives are involved in the care plans. The home administers medication appropriately to all residents. There is good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. EVIDENCE: A review of all information available prior to this inspection and previous key inspections carried out at this home has evidenced that either residents or their relatives are involved in the care plans. Those care plans seen had been signed to confirm that residents agree with the care being provided. Two relatives seen confirmed that they have been actively involved in their relatives care plans. Both visitors said that they attended the six monthly review of their relative last week at the home. They also stated that their relative is always well dressed clean and treated with dignity and respect. One resident ‘stated that this is a smashing place and I have settled in well’. She said that staff are very good and her key worker helps her when she has a Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 11 bath. The second resident who was being case tracked confirmed that she had an eight week review and filled in a questionnaire relating to her views of the care she receives. She also said that staff are very kind. Care plans evidenced that health care professionals visit the home and that residents when required visit the hospital. The homes pre-inspection questionnaire listed the health care support services available to residents at this home. Residents questionnaires received back from the home showed overwhelmingly that residents felt that they receive the medical support that they need. Residents files also showed that personal care required is documented and mention is made of maintaining the residents dignity and privacy at all times. Daily entries had been made in care plans by care staff, which identified the care given. Residents questionnaires showed that twenty-five felt that they received the support that they need and five said that they usually receive the support that they require. Two residents said that they sometimes receive the support that they need. Care staff were seen to treat residents with respect and dignity during this inspection. The homes accident book was seen and it was found that accidents occurring to residents have been recorded appropriately. The homes service history kept by the Commission demonstrated that all incidents/accidents affecting the welfare of residents is also made available to the Commission by the home. One carer demonstrated that she had knowledge of giving personal care and confirmed this is addressed in the homes induction training and NVQ (National Vocational Qualifications) training. Medication sheets seen were found to be correctly completed by the senior on duty. The pharmacist inspected the home on the 02/05/06 and recorded that storage and administration records of medication is carried out appropriately and no recommendations were made. The homes training file evidenced that care leaders receive training in the administration of medication. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. Meals are well managed and reflect resident’s likes and dislikes. Relatives and friends of residents are made welcome in this home. A range of stimulating activities are made available to residents. EVIDENCE: The home undertakes a variety of activities for the stimulation of residents. The homes activities diary showed that on five days of the week activities are made available both by the activities organiser and care staff. The notice board also listed a weekly events within the home for the information of residents. As well as local schools coming into the home at Christmas some residents attended a schools VE day celebrations. A residents stated that she has holy communion weekly when the priest visits her. The activities organiser evidenced in her activities book all those activities, which takes place. This included coffee mornings being arranged, cake decorating, photographs taken and framed by residents, darts, outings and the summer fete. Twenty residents questionnaires showed that there are activities and they are available to them always, ten residents commented that activities are usually Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 13 available and one said never. Two residents commented that ‘we play darts, throw bean bags and have quizzes. The minutes of the residents meeting held on the 11/04/06 evidenced when forthcoming entertainments/activities and outings would take place at the home. Residents stated that their visitors are made welcome and that they can be seen in the privacy of their room. One resident comments that ‘my visitors come on a Saturday and always get a cup of coffee. The homes signing in book showed that the home has a large number of visitors during the day and evening. Visitors confirmed that they are made welcome at the home. The inspector joined two residents for lunch and found that the meal was hot and very tasty and that choices were available. Residents questionnaires evidenced that twenty-three always liked the meals and six usually did with three residents stating they sometimes liked the meals. One resident commented that he would prefer more pasta dishes. This resident was seen at this inspection and confirmed he gets dishes of his choice. The cook commented that she was aware of residents dietary needs and had information relating to any allergies. She also evidenced that a quality assurance check is carried out weekly with residents being asked about the food served with comments recorded. The cook is qualified to carryout her tasks. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The home takes the issue of addressing complaints very seriously and has a comprehensive complaints policy. Staff are aware of how to respond to a complaint or an adult protection allegation. EVIDENCE: Previous inspections of this home has shown that a detailed complaints procedure is in place. The homes complaints pre-inspection questionnaire recorded that no complaints had been made in the last twelve months. The home sends a letter with a return slip to complainants to sign confirming that their complaint had been addressed satisfactorily or not. Residents questionnaires showed that residents were aware of how to make a complaint and knew who to speak to if they were unhappy. One carer commented that she had undertaken safeguarding vulnerable adults training and was aware of the meaning of abusive practices. Residents response to the Commissions questionnaire showed that twenty-one said staff listen and act on what they say and ten said that they did usually, with two stating sometimes. One resident stated that ‘she feels safe here and sleeps well’. Another resident said that ‘I feel safe here I was always falling down at home. She went on to say that ‘when I ring the bell staff come quickly’. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained, the standard of the environment and its facilities are appropriate to the needs of residents. The home is clean and free of unpleasant odours. EVIDENCE: Previous inspections have found that; the home has a maintenance record which records work that has been undertaken and projected work for the coming year. A partial inspection of the home found that it was in a good stated of repair both externally and internally. The homes pre-inspection questionnaire evidenced that various bedrooms have been redecorated as well as one lounge. An inspection carried out on the 28/11/05 found that the home employs five cleaners who are allocated designated areas to clean. A partial tour of the home found it to be clean and had a pleasant smell throughout. Visitors stated Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 16 that they have not detected any unpleasant odours during their visits. Residents responses seen in the questionnaires were unanimous in that the home is always fresh and clean. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Appropriate recruitment practices are in place. Staffing level meets the needs of residents. The home provides adequate training for care staff. Staff were seen to be competent in carrying out their care tasks. EVIDENCE: A review of all information available prior to this inspection including the homes action plan from the inspection carried out in November 2005, showed that; all care workers have been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes pre-inspection questionnaires evidences that thirteen carers have NVQ (National Vocational Qualifications) and the home now meets the ratio of 50 of care staff trained to level 2. The questionnaire completed by residents showed that twenty-five said that they receive the care that they need and twenty-one said that staff listen to what to what I say and act on it. The homes pre-inspection questionnaire evidenced that there are seventeen care staff, eighteen ancillary workers four care leaders and a registered manager. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 18 One carer commented that she has NVQ level 2 and hope to do NVQ level 3. She also stated that there are enough staff and we spend time with residents. The duty rota showed that adequate staff numbers are on duty to meet the needs of residents during the day and night shift. The carer confirmed that that she has undertaken mandatory training as well as induction training carried out at the home and two days at Wellingore (Headquarters). The manager confirmed that Skills for Care training packs are being introduced to the home. The home also carries out appropriate checks for all new workers before they commenced work at this home. Evidence was seen in personnel files to confirm that these checks are undertaken. One resident said that staff are very good and can find no fault with them. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is qualified, competent and of good characters to carryout her duties. Records seen show that residents’ health and general welfare and safety are promoted. The home ensures that that the residents have the opportunity to voice their views and opinions. Accurate records are kept of residents’ monies. EVIDENCE: The registered manager has worked for sixteen years at this home. She started as a night care assistant before moving to day shifts where she became an acting care leader, then a care leader, acting manager and in October 2005 she became the homes registered manager. During this period she has gained experience at differing levels of care work before becoming the registered Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 20 manager of this home. The manger is currently undertaking the Registered Managers Award and then NVQ level 4 in care. The home conducts a six monthly quality assurance report. The April/May 2006 report has been made available to residents and relatives in the reception area of the home. The home only deals with personal allowances of residents, which are kept safe. All other monies relating to funding are paid into the companies bank account. Two residents allowances were checked and an accurate record was kept, with two signatures and receipts available for monies spent. Two visitors stated that they deal with their relative’s finances. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. The homes pre-inspection questioner evidenced that fire alarm, fire drills and emergency lighting checks have been undertaken. Care staff also receive fire training as part of the homes initial training and as a regular training event. The homes pre-inspection questioner evidenced that bath hoists, wheelchairs had been serviced on the 03/11/05. All wheelchairs seen on the day of the inspection had footplates, which were in use. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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 2 3 x x x 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 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 4 x x x x x x 4 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 x 4 x 3 x x 4 Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 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 OP2 Good Practice Recommendations The home should check that terms and conditions in respect to accommodation to be provided to residents including as to the amount and method of payment of fees are available in all residents files and residents are advised as to this. Foxby Court DS0000002361.V293386.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. 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