Inspection on 24/06/05 for Foxby Court

This inspection was carried out on 24th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10/05/06

Foxby Court 28/11/05

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 Doug Tunmore Unannounced 24 June 2005 09:00 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. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Foxby Court Address Middlefield Lane Gainsborough Lincs DN21 1QR 01427 613376 01427 616329 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) The Orders of St John Care Trust Care Home 47 Category(ies) of Old age (OP) - 47 registration, with number of places Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30 November 2004 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 Giansborough, 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 cliose 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. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10.40 am. The main method of inspection used was called case tracking, which involved selecting two residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observations of care practice. A community nurse was also seen during the course of the inspection. A partial tour of the premises took place. What the service does well: What has improved since the last inspection? What they could do better: Residents care plans must record the personal preferences of residents regarding their privacy and dignity in relation to providing intimate care. The home must record all accidents to residents as per their policies and procedures. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 6 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 C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 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 Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 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 Residents are admitted into the home only after a full needs assessment has been carried out either by the home or health care or social care agencies. Written confirmation that the home can meet a prospective residents needs is also undertaken prior to admission. EVIDENCE: The home has a detailed admission procedure, which identifies the needs of residents coming into the home. Residents spoken to were not always able to give a considered view of the care they receive due to their age and those infirmities that come with old age. However, one resident said that she was visited prior to admission by someone from the home and that her family were involved in this process. Both residents had an assessment undertaken either by the hospital or the Social Services Department. Files seen showed that residents received a letter from the home confirming that the home could meet their needs. The care worker spoken to knew about the care needs of residents and was aware of the homes pre-admission assessment procedures. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 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 and 10 There is good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. Training relating to the delivery of personal care is not sufficient and needs to be reviewed. EVIDENCE: All residents have detailed care plans, which describe their health and welfare needs. Care plans outlined risk assessments, nutritional and dependency assessments. Care plans also evidenced that they have been reviewed on a monthly basis or sooner depending on changing needs. The review of one resident had not been signed or dated by the carer or the resident. This must be undertaken to ensure that all parties are in agreement with the outcome of the review. Two files showed that care plans had been signed by the residents. One resident could not remember if she signed her care plan. She said that ‘ they (the staff) do everything for me I am very pleased with it, looked after very well’. The commission received thirty-three comment cards from residents and thirteen from relatives. Twenty-nine residents comment cards confirmed that ‘they feel well cared for at this home and 2 felt that they were well cared for sometimes’. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 10 Individual care plans evidenced that accidents are recorded in the home’s accident book and in the resident daily notes. The home also uses body maps for the mapping of any cuts or abrasions to residents. One accident form was checked through the homes accident procedures and it was found that abrasions to a resident had not been recorded appropriately on the body map. One visiting community nurse confirmed that there was good communication between the home and herself. The community nurse also said that staff were helpful and could follow instructions given to them regarding the care of residents. Files seen confirmed that health care professionals visit the home when required by the residents. A carer was aware of the intimate care needs of residents but could not remember if this issue was undertaken during her induction training. It was also noted that the homes initial training format for new care workers did not address issues relating to maintaining residents privacy and dignity when undertaking intimate care needs. Care plans also did not record the need to maintain the privacy and dignity of residents. A resident commented that ‘everything is done properly and they talk me through things and they are very friendly’. The pharmacist inspected the home on the 21/05/05 and recorded that storage and administration records of medication is carried out appropriately and no recommendations were made. A number of residents look after their own medication and a lockable facility is available to them for its safekeeping. Risk assessments were seen and had been signed by resident acknowledging that they can look after their own medication needs. The home has instigated further medication training for all staff due to a medication error. A care worker confirmed that she is undertaking medication training through Grantham College and will take the exam shortly. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 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 standard(s) 13 and 15 Relatives and friends of residents are made welcome in this home. Meals are well managed and reflect resident’s likes and dislikes. EVIDENCE: The homes visitors signing in book was seen and showed that numbers of visitors attend this home on a daily basis at differing times of the day. The community nurse confirmed that she is always made welcome when she visits. Residents confirmed that they have visitors in their rooms and that they are made welcome by care staff. One resident said ‘my family have always been involved in my care and still are, they visit regularly and are made to feel welcome’. The inspector joined three residents for lunch and found the meal provided to be hot and delicious. Residents said that they have a choice of meals and they particularly like the food served in tureens so that they could help themselves. The cook was spoken to and recorded in her files the likes and dislikes, as well as specialised diets required by individual residents. Residents comment cards showed that seventeen liked the food at the home and the rest sometimes liked the food. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 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 and 18 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: The home has displayed the service users guide, which contains the homes complaint procedures in the main entrance. The home has a detailed complaints procedure. The homes complaints log was seen; one complaint had been made since the last inspection and the Commission has asked the providers to carryout a further investigation into this complaint. The complaints log did not have a space for complainants to sign confirming that their complaint had been addressed satisfactorily or not. Residents commented that if they had a complaint they would see a senior carer or the manager, who they felt was approachable. None of the residents spoken to said that they had problems with any care worker. Relatives comment cards showed that ten of the thirteen stated that they were aware of the homes complaints procedure. All thirteen comment cards indicated that they were satisfied with the overall care provided. Residents comment cards showed that twenty-eight felt safe in the home and the rest had not ticked the appropriate question. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 13 A carer commented that she was aware of the homes ‘Whistle Blowing’ policy and spoke knowledgeably about abusive practices and what action she would take if this came to her attention. Staff received adult protection training as part of their ongoing training in January 2005. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 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 standard(s) 19 The home is well maintained, the standard of the environment and its facilities are appropriate to the needs of residents. EVIDENCE: The home has a maintenance record which records work that has been undertaken and projected work for the coming year. Since the last inspection eight bedrooms have been decorated and door locks fitted to ensure the privacy of residents. Projected work for the coming year is for serving bays in the dining room to be replaced and for one day room to be decorated, with wall lights fitted. Residents seen during the tour of the building said that they like their rooms and are able to personalise them with their own possessions. One resident commented that she has access to the garden where she feeds the birds. Residents’ files showed that risk assessments were available which highlighted risks to residents posed by the homes environment and action to be taken. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 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 The numbers of staff are sufficient to meet the needs of all of residents. EVIDENCE: The staffing roster was seen and evidenced that adequate staff numbers are maintained for the needs of residents. Relative’s feedback cards showed that nine of the thirteen felt that there were enough staff on duty. The majority of resident’s feedback cards recorded that they liked living in the home and they felt well cared for. The acting manager commented that one resident who needed nursing care was to move to a nursing home in the near future so that her needs can be met. An appointment of an extra care worker is to be made who will cover the 6.30 am to 9.30 am shift which is one of the busiest times of the day. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 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 The home promotes the best interests of residents by obtaining their views regarding the way the home is managed. EVIDENCE: The home carries out an eight weekly and six monthly review of residents care needs in which residents, relatives and social workers can attend. This review process looks at ongoing needs of residents in which they play a major part. A client quality assurance form is given to the people attending the review and their views are sought regarding all aspects of the service provided at this home. The home also has a questionnaire for residents who have been living in the home for a short time which asks questions regarding the way the initial admission was carried out and the residents satisfaction or otherwise regarding the services available to them within the home. The home also has an entertainments meeting with the last one being held on 23/03/05 as well as residents meetings being held on 03/05/05. The minutes of these meetings are posted on the residents notice board for the their information. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 17 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x x Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 18 no 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. 2. 3. Standard 7 8 10 Regulation 15(2)( C) 17(a) 12(4)(a) Requirement Timescale for action 25/08/05 The home must ensure that all reviews are dated and signed by the resident and senior carer. The home must record all 25/08/05 accidents in line with its policies and procedures. The home must record how they 25/08/05 are going to maintain the privacy and dignity of individual residents in their care plans. 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 16 Good Practice Recommendations The homes complaints form should have a space for complainants to sign regarding their agreement with the outcome or not. Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Foxby Court C53 CO4 S2361 Foxby Court V234846 240605 Stage 4.doc Version 1.40 Page 20 - 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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