Care Home: Footherley Hall

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What the care home does well The home has been refurbished and extended to improve standards and facilities for the people using the service. People can be assured when moving into Footherly Hall, that a thorough assessment has been carried out and the home can meet their needs. People we talked to spoke highly of the home, and the care provided by the sisters and the staff. People using the service said that health care needs are promptly met, the staff provide good quality care within a calm and caring atmosphere. There is a long standing group of staff at the home, all have received national Vocational Training. There is a good choice of all types of food for any preferred diet. What has improved since the last inspection? The extension work has now all been completed and registered providing high quality facilities. A new catering company has been employed, specialists in providing food for the elderly in care homes. Menu plans have been reviewed and new ideas adopted by staff, people using the service have inputed ideas. A full time social activities co-ordinator has been employed, in order to promote the well being of people using the service. New activities and outings have been implemented, the day before this key inspection a group of people had been to a craft centre at a farm, and to staffordshire wildlife trust. Changes are made in the care plans in order to meet the needs of the people using the service. Staff have received training in the care of the dying in order to meet the needs of people of all religions. New pastoral care team with two of the sisters, secretary, and activities organisor. The team visit people in their rooms if they are poorly, and talk to staff and people using the service who want to talk to them. What the care home could do better: The services main objective is the general well being of the people using the service, therefore any improvements that will benefit them the service are ready to listen to and implement. If something is not possible then the service will give reasons why not. Key inspection report Care homes for older people Name: Address: Footherley Hall Footherley Lane Near Shenstone Lichfield Staffordshire WS14 0HG     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Kathryn Marks     Date: 2 8 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Footherley Hall Footherley Lane Near Shenstone Lichfield Staffordshire WS14 0HG 01543480253 01543481548 manager.footherley@hsc-uk.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Sisters Hospitallers of the Sacred Heart of Jesus care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 50 The registered person may provide the following categories of service only: Care Home Only (Code PC) To service users of the following gender Either Whose primary care needs on adission to the home are within the following categories: Old age not falling within any other category OP 50 dementia (DE) 20 Date of last inspection Brief description of the care home Footherly Hall is a 50 bedded Care Home for elderly people situated in the Village of Shenstone Nr Lichfield Staffordshire. The three-storey property is situated in attractive grounds with panoramic views from areas of the home. The home has been subject to major refurbishment/extension work to upgrade and improve facilities, this has now been completed. The registration category identifies that the home is registered to provide a service for individuals with a physical disability and dementia. The home is Care Homes for Older People Page 4 of 28 Over 65 0 50 20 0 Brief description of the care home run by members of an order of sisters founded solely for the purpose of providing care with a positive ethos on religion of all denominations. The accommodation of people who use the service is provided on all floors, bedrooms are nicely decorated and designed to meet the needs and reflect the personality of the Individual. Bathrooms and toilets are located throughout the home in close proximity to both communal areas and bedrooms. Grab rails, hoists, nurse call alarm systems and ramps were available around the home promoting the independence of people who use the service. Spacious lounge and dining areas with views over the grounds and a conservatory providing a quiet area. Laundry facilities were provided, having staff appointed within this area to launder all clothing and linen for individuals at the home. An impressive chapel was adjacent to the home providing an area for people who use the service to practice their religious faith. Information gained from the Head of Care identified that the current fees charged are from £410 to £530 per week. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection was carried out on Tuesday 28th July 2009 by one inspector who used the National Minimum Standards for older People as the basis for the inspection. The Inspector was accompanied by an Expert by Experience. The last Key Inspection on this service was 15th August 2007. On arrival for this inspection the Head of Care, nine care workers, six sisters as carers, three gardeners, four housekeeping staff, two laundry persons, receptionist, hairdresser, one cook and three kitchen assistants were on duty. The Care Manager and Head of Care provided written information regarding staffing, staff training, menu and dietary provision, that was observed to be in place at the home. We discussed with the Head of Care and the Sister in charge arrangements for the day, Care Homes for Older People Page 6 of 28 to avoid disruption to people using the service, staff, and routines in the home. We spoke to people using the service, and their relatives who were visiting them. We sampled the financial records of four people using the service. Four peoples care records were checked, and the records of three staff, including recruitment and training records. We discussed the food with people living in the home, observed lunch being served, and talked to the chef. We also looked at the Annual Quality Assurance Assessment (AQAA) this is a self assessment tool, and had been very well completed with a lot of detail, and sent to us prior to the key inspection. Completion of the AQAA is a legal requirement and it enables the service to undertake a self assessment, which focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Care Homes for Older People Page 8 of 28 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who wish to use the service have the information they need to make an informed choice about living at the home. Evidence: The AQAA we received prior to the Key Inspection told us that The service has in place a Mission Statement. The Home has a policies and Procedures manual which is reviewed regularly, the service are now in the process of reviewing all of the policies and procedures. The service have produced the Statement of Purpose which is given to all prospective people wishing to use the service, and their immediate relatives. This describes the service and the facilities the home offers, and is reviewed as required. The AQAA also tells us that the service have a Guide for People who use the Service which is given to all people on admission. This repeats much of the Statement of Purpose material with additional information on access to services, and how to make a complaint. These documents are reveiwed and updated regularly. Potential people are encouraged to view the home, and, if it is not possible then Care Homes for Older People Page 11 of 28 Evidence: management visit them to do a proper pre-admission assessment. Relatives and friends are involved in this process as appropriate. An individual agreement is issued for each person on admission with the terms and conditions of the home, every person is given the oportunity to come on a trial basis of 5 to 6 weeks. A full pre-admission assesment is done of each person before they are admitted, once the person is in the home an individual care plan is done and reviewed monthly or as required. People are taken for respite care to maximise their independence before they go home, or to relieve the person caring for them. Assessment of their needs is done and reviewed as required. We saw the homes Statement of Purpose and Service Users Guide that provide detailed information for people wishing to use the service, including fees charged. We saw information on care records that told us families had visited Footherly Hall prior to the person being admitted. We talked to peoples relatives who were visiting the home, they told us that they had visited the home prior to the person being admitted. We saw the care records of four people using the service and examined them in detail. Peoples records contained information collected by the Care Manager, and the Head of Care, who carried out the assessment. We saw risk assessments in place that included manual handling, nutritional assessments, mobility and mental well being. Risk assessments were signed and dated. This means that peoples needs had been assessed, and the home was satisfied it could meet those needs. The home does not provide intermediate care. We received seven surveys from people using the service. Surveys told us that six people received enough information about the home to help them decide before moving in. One person their relatives received the information. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people using the service are met, personal care is delivered in the way the individual wishes. Evidence: The AQAA we received prior to the Key Inspection told us that The service carries out a full assessment of peoples needs that are reviewed regularly. Individual care plans and risk assessments are in place, and they are reviewed as required at least once a month. There is daily recording of incidents, accidents and minor changes. Training of the staff and continuous supervision, make sure the staff treat the people using the service, and one another with respect, privacy and dignity. A blister pack medication System is used in order to avoid mistakes. The AQAA also tells us that People are encouraged to self medicate once they have been assessed by Doctor and Manager or Head of Care. People are registered with the local General Practitioners and District Nurses and other professionals as required. Families are involved in the reviewing process of the care plans. The home have completely open visiting arrangements and encourage relatives to assist with the general care. Most people have their own private telephone line in their bedrooms. Care Homes for Older People Page 13 of 28 Evidence: We looked at the care records of four people using the service during this inspection. We saw that records contained information regarding health care, personal care, and risk assessments that are reviewed on a monthly basis. Reviews are carried out more frequently if required. We saw health care records that identified people are registered with the local health care practice. Appropriate referrals are made to professionals as necessary. We observed medication administration stores on each floor. Medication is administered from a blister pack monitored dosage system, with the exception of medication not compatible with the system. We saw records that identified medications are administered by staff who have been trained in the management of medication. We saw risk assessments in peoples care records that identified areas where support is required, and how it would be given. Nutritional risk assessments are in place. We saw throughout this inspection that the privacy and dignity of the people using the service was respected, and people were dealt with in a courteous manner. We received surveys from seven people using the service that told us that they receive the care and support that they need. We received a survey from the district nursing team that told us As a team of district nurses we have always found that the care at Footherly Hall has been provided to the best of their knowledge, education is a priority so the staff act in an appropriate manner. Seven people told us that they always get the medical care they need. Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service make choices about their daily lifestyles, with visitors to the home being made welcome. The food provided is of a high standard, with a varied nutritional diet being offered. Evidence: The AQAA we received prior to the Key Inspection told us that The service strive to promote a warm, welcoming, relaxed and comfortable environment for the vulnerable older people that they take care of. The service aim and work to promote their independence so every one is able to maintain their life style as much and as long as possible. The service have a mini bus to take people out and also hire the Voluntary Local Transport when wheelchair users are taken out. The home and every member of the staff is trying to meet and satisfy all the needs of each of the people, physical, mental, social, religious, cultural and recreational interests, in one way giving a holistic care. We employ a full time activity co-ordinator who is very creative and able to motivate, support and promote interest in the daily activities. We have the support of a group of volunteers who provide regular entertainment and opportunities for outings to places of interest among the people who use the service. There are areas in the home where the people can meet with relatives, friends, or professionals and not be disturbed. Care Homes for Older People Page 15 of 28 Evidence: We saw that there was a notice board in the kitchen hallway and the lounge displaying pictures of the residents. We saw that a daily activities programme is in place, that involves and provides for the social needs of all people living in the home. This included word games, quizzes, and pottery sessions. The activities person we spoke to showed us how she kept a record of activities, both inside and external outings. We saw in the main lounge in the afternoon various activites taking place, that people were involved in and enjoying. The lounge has a partition wall where the old building ended and the extension began. Exercises were taking place during the morning with the carers and sisters encouraging people who were seated on the other side of the partition. There was a dog therapy session for one person in the morning. We saw a visiting staff member who had brought in a chicken and a puppy in the afternoon, that the people using the service were very interested in. We discussed the need for a risk assessment to be put in place with the Head of Care, to ensure the safety of the people using the service. We saw that the staff on duty interacted and stimulated the people they were caring for and involved them in activities. The news headlines are read out to people, both local and national. They are then displayed for people who may wish to read them. We saw that the hairdresser was also visiting during this inspection, people told us that there is also a visiting beautician as well as them practicing manicures on each other. We chatted to people in the lounges and in their bedrooms, people told us they were happy at Footherly Hall. The sisters take people out in the mini bus when they go shopping, and to the local garden centre for coffee and a look around. We looked at the care records of four people, we observed reviews, and risk assessments, we observed the personal allowance and the records relating to this. We saw the menu displayed on the notice board in the dining room, with alternative choices available. We saw the food being served to people, this was nicely presented and portions were generous. Care Homes for Older People Page 16 of 28 Evidence: We saw that the people with dementia who needed assistance to have a meal, this was done in a discreet and sensitive manner in their own dining area. In some cases the Sisters of the Order made informed choices of menu for people whose likes and dislikes they were familiar with. We did however suggest that pictures of food may assist people to make their own choice. We observed the people with dementia having lunch, there were two members of staff assisting four people using the service. The expert by experience observed that one member of staff who was helping a person to eat their meal, did not tell the person what she was eating. The other member of staff was assisting two people, one of whom kept falling asleep whilst eating. We discussed with the Head of Care that people with dementia are assisted at meal times on a one to one basis, this will enable staff to explain what is for lunch whilst helping them with their meal. We talked to people after lunch and they told us they had enjoyed their meal, and that the food was very nice at the home. Comments made by them were, food is excellent Quite nice food Food very good, excellent There is always a choice. The Sisters and the people using the service all have the same food menu to select from. Staff training records told us that food hygiene training for staff needs to be updated. Training records identified that this is booked for September 2009. We received surveys from seven people using the service. Four people told us that there are always activities available Three people told us there usually are. Three people told us they always like the food, three people said they usually do, one person said sometimes do. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make complaints and are safeguarded by the homes procedures. Evidence: The AQAA we received prior to the Key Inspection told us that The Home has a clear and accessible concerns and complaints policy and procedure illustrating how complaints are dealt with. The service always strive to listen to the people using the service, their relatives and friends, and other professional visitors, about their concerns and worries. All complaints and incidents are investigated immediately. Staff are supervised, counselled, retrained, and disciplined accordingly. All staff have been given training in order to be able to identify any signs of abuse and how to deal with this. Protection of Vulnerable Adults procedures are in place to respond to evidence or suspicion of neglect. The Statement of Purpose and Service users Guide have details of how to complain and to whom to complain, including contact details for the Care Quality Commission and copies of this procedure is avalibale throughout the home. The home will not tolerate any form of abuse in any of its types, does not matter how small the incident, it will be always investigated and act accordingly. We saw the home has a complaints book in place, no entries have been made since August 2007. There have been no complaints made to the home or to the Commission. Care Homes for Older People Page 18 of 28 Evidence: We talked to people in the home and their relatives. people using the service said they would talk to staff or a relative if they were unhappy about something. We looked at the finances of four people using the service, the cash balanced with the records kept. We saw staff training records that identified staff have received training in the Protection of Vulnerable Adults, the Mental Capacity Act and Dementia Awareness. Staff we spoke to were aware of and able to discuss equality and diversity, all people using the service are offered the same choices. We saw on staff files that Criminal records bureau and protection of vulnerable adults checks are carried out, two written references are taken up prior to employment. We received seven completed surveys from people using the service that told us that seven people said they knew how to make a complaint The expert by experience talked to people using the service who told her that, they felt they were able to talk to anyone in the home, about anything they were unhappy about. They also said they had no complaints about the home or the care they were receiving. One of the people said I have no complaints, my only complaint is with myself, I cant do all the things I used to. Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables people to live in a safe, clean, well-maintained and comfortable environment. Evidence: The AQAA we received prior to the Key Inspection told us that A lot of work, effort and money has been spent in order to upgrade the home and to ensure that the people using the service live in a safe ,clean, comfortable and homely environment. Footherly Hall has been maintained clean and safe as far as possible and this is something we are very proud of. The Home provides infection control training to staff so they are aware of the importance of prevention. We encourage the people using the service to personalise their rooms with their own furniture, fittings and ornaments. We provide well maintained and extensive gardens,so people can enjoy the peace and beauty of nature, the outdoor space is accessible to all service users including those with mobility problems. The home complies with the requirements from the local fire service. Toilets and bathing facilities are available to meet the needs of the people using the service, adapted equipment is provided within the home such as grab rails, ramps, hoists and wheelchair. Each bedroom has a call bell system as well as toilets, bathrooms and communal rooms. We saw on arrival that the foyer of the home and the staff were very welcoming. There was a very calm and relaxing ambience. We saw a person using the service Care Homes for Older People Page 20 of 28 Evidence: talking to her family as we entered the home. We saw the physical design and layout of the recently upgraded home, meets the needs of the people using the service. The communal areas are comfortable and the new extension part of the home has been done to a high standard. We observed that the names on bedroom doors were typed on paper and then laminated. As people are doing plaques and dishes in pottery sessions, maybe they could do nameplates for bedroom doors. We saw that people using the service were relaxed in their surroundings, that both visitors and people living at the home were moving freely around. We observed lounges to be very busy with an activities person involving everyone in the activities taking place. We saw that Health and Safety checks are carried out, Fire Equipment is serviced, Lifts, Hoists, and water checks are all in place. We saw that good infection control practices are in place, twenty seven staff have received Infection Control training. Policies and procedures were in place for the control of infection. The cleanliness of the home throughout is maintained to a very high standard and is a credit to the housekeeping staff. One of the people using the service mentioned to the expert by experience that the rooms were cleaned discreetly, the person leaves the room and only then are the rooms cleaned so they are not disturbed unnecessarily. Seven people using the service returned completed surveys to us and told us that the home is always fresh and clean. Care Homes for Older People Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A well-trained and consistent staff team support the people using the service. Evidence: The AQAA we received prior to the Key Inspection told us that The service are constantly striving to ensure adequate staffing levels and mix of skills, care workers, seniors, activities, pastoral care, and administration. The service as an organisation recruit in a fair and open way ensuring we employ the right people without discrimination. We carry out various checks on possible employees for example, Criminal Records Bureau, references, employment history. We invite prospective staff to come to more than one interview. All employees receive a job discription and a hand book, induction training and regular updates. We have well over 75 of staff with National Vocational Qualification level 2 and several of them with National Vocational Qualification level 3. The home displays a rota clearly showing what staff is on duty at any specific times. There is a very comprenhensive training programme, covering not only the obligatory training requirements but also including subjects that will help to provide better care, and promote staff development The group of Religious Sisters living in the premises support the staff and help them with the care of the people using the service. We saw on arrival at the home today that the following staff were on duty as identified on the staff rota. Head of Care. Six of the sisters working as carers. Nine Care Care Homes for Older People Page 22 of 28 Evidence: Assistants. Three Gardeners/ Maintenance. Four Housekeeping staff. Two Laundry persons. Receptionist. Hairdresser. Activities Person. We saw the staff records of the last three people employed at the home. The last person who started told us he received two months mentorship with a senior care, and talked positively about the induction he received. We saw that staff received a general induction to the service then continued to work with an experienced member of staff during their induction period. We saw records that told us staff received appropriate pre-employment checks before commencing employment at the home, application forms and references were on file. We talked to the Head of Care who told us she felt well supported by the Sisters and the management of the home. The Head of Care also told us recruitment is via the local newspaper, job centre, or word of mouth recommendations. We talked to members of staff who told us they received regular training opportunities, the training matrix confirmed this. We talked to staff in the dining room at lunchtime and to the cook, who told us that provisions are plentiful and fresh produce is used. We received surveys from seven people using the service. Three people told us that staff are always available, four people said they usually are. Five people told us that staff always listen to them and act on what they say two people said they usually do. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are safeguarded by competent management systems. Evidence: The AQAA we received prior to the Key Inspection told us that The Home is operated in the best interest of the people using the service and in accordance with our Mission Statement that emphasises them as the core of our activity; Footherley Hall is run by a charitable organisation with non profitable status and a 128 year history of involvement in this kind of work. All the staff have induction training, at least yearly appraisals, and individual and group supervision. The manager of the home has over 30 years experience and there is a very good management team. Two of the staff team with National Vocational Qualification level 4 in management and care. The home has got a set of policies and procedures and they are monitored by the Head Quarters of the Sisters in London, the person in control visits very regularly at least once a month. The Mission statement and ethos of the Home is to provide a homely,comfortable and safe environment for the people using the service. To assist people in the last years of their life to live a life style suitable to their age and Care Homes for Older People Page 24 of 28 Evidence: capabilities. We looked at records that told us the manager is experienced and qualified, she has the Registered Managers Award, Safe Handling of Medicines, a certificate in Occupational Health and Safety, and is a National Vocational Qualification Assessor. We saw that the management team is made up of four people. Two sisters, the Head of Care and the homes Administrator. This team meets on a regular monthly basis to discuss forward planning of care and other events in the home. This provides good leadership and staff knew what was expected of them. We saw monitoring systems in place, the Head of Care monitors the well being of the people using the service and the practices in the home. We saw a sample of questionnaires that had been sent to relatives and people using the service. We saw robust systems in place for the management of peoples personal allowance, records are audited on a regular basis. We looked at the finances of four people using the service, cash balanced with records maintained. We observed safe working practices to be in place, records show that equipment is serviced regularly. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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