Christ the King, Footherley Hall

Updated 11 November 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of 2 inspectors, a senior performance coach who was observing the inspection process, and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Christ the King, Footherley Hall is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Christ the King, Footherley Hall is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had about the service. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with 12 people who lived at the home and 5 of their relatives and friends. We spoke with 8 members of staff including the registered manager, the Head of Quality and Compliance, 2 senior care workers, 2 care workers, 1 receptionist and 1 maintenance worker.

We reviewed 6 people’s care plans, medicines records, accident and incident records and safeguarding records. We also reviewed records relating to training, recruitment, quality assurance and feedback and complaints.

Updated 11 November 2023

About the service

Christ the King, Footherley Hall is a residential care home providing accommodation for to up to 50 people who require personal care. The service provides support to older people, people living with dementia and people who have a sensory impairment. At the time of our inspection there were 48 people using the service.

People’s experience of using this service and what we found

We were not assured that the provider was responding effectively to risks. Medicines were not always managed in a safe way. Systems and processes in place to safeguard people from the risk of abuse were not always effective. Lessons from incidents were not always discussed with the staff team.

People were at risk of receiving inconsistent care and support as not all staff had received the required training. People’s needs were not always assessed effectively. The provider was not always working within the principles of the Mental Capacity Act (MCA) because not all care plans included mental capacity assessments where required. The MCA is designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. The systems in place to assess and manage the quality and safety of the service were not always effective.

People had a variety of food and drink to meet their needs. The provider worked effectively with other agencies. The design, layout and furnishings in the home reflected people's individual needs.

People were treated well and respected as individuals. People felt listened to and valued by staff. People's dignity was respected in the way staff spoke to people and acted towards them. There were enough staff to support people safely. Staff were recruited safely.

People received individual, person-centred care. Care plans contained clear information about how best to support the people with their communication needs. People had opportunities to do things they enjoyed. People, and those important to them, could raise concerns and complaints. The provider supported people appropriately with end of life care and liaised with the GP when people’s end of life needs changed.

People achieved good outcomes from their care. Staff felt valued and supported by the management of the service. Relatives were involved in care planning and were regularly informed of how their relatives were getting on. The provider understood and met the duty of candour. Staff worked with external professionals which included GPs, advanced nurse practitioners, the falls team and district nurses.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

This service was registered with us on 02 February 2023 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about people’s care needs, assessing risk and staffing. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service was requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to the safe care people receive and the overall governance of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.