Christ the King, Footherley Hall

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to people’s safe care and treatment, risk management and medicine management.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not always a proactive and positive culture of safety.

Practices around incident and event reporting were inconsistent across the service. Some staff did not always report concerns in line with policy or best practice. This meant that management were not always aware of incidents that had occurred within the home and were therefore unable to investigate or respond appropriately. The lack of oversight and follow-up limited opportunities for shared learning and improvement, ultimately impacting the development of a positive and open learning culture.

Safe systems, pathways, and transitions were not always effective, as key information was not consistently shared between teams and services. Records were not always updated, or on occasions, information about people’s needs had not been recorded.

This lack of effective recording led to gaps in care and coordination, which negatively impacted the safety and experience of people using the service and increased the risk of avoidable harm.

However, the registered manager had developed a good working relationship with the local GP, who spoke positively about the work the registered manger and the staff were doing.

Safeguarding processes were not consistently followed, which compromised people’s safety. Incidents were not always reported to management in the correct way, and when they were, management did not consistently recognise or escalate these as safeguarding concerns. This led to missed opportunities for appropriate referrals and intervention, placing people at potential risk.

The registered manager was receptive to our feedback and had started to take actions to ensure effective safeguarding systems were in place.

Risks to people's health and wellbeing were not always effectively assessed or managed.

Care plans did not consistently contain detailed information about individuals' specific needs. For example, people who required regular repositioning did not always have appropriate charts in place to monitor this. In some cases, risks remained unaddressed, leaving individuals exposed to potential harm. Additionally, people with specific health conditions, such as diabetes, did not have tailored care plans to guide staff in delivering safe and appropriate care, which further compromised risk management.

The provider had effective systems in place to detect and control potential environmental risks within the care environment.

Staff took proactive steps to ensure that the premises were safe and well maintained, with regular checks and risk assessments carried out.

There were enough qualified, skilled, and experienced staff who received effective support, supervision, and opportunities for professional development. However, some staff expressed concerns about staffing levels during night shifts, suggesting that more support may be needed. One staff member said, “It is hard work on nights because people’s needs have increased over time.”

In response, the manager acknowledged this feedback and committed to reviewing staffing levels using a different dependency tool to ensure appropriate cover.

The home was visibly clean and well maintained, where domestic staff were observed throughout the day. The environment was free from unpleasant odours and smelt clean.

However, some concerns were identified in relation to equipment hygiene. For example, pressure-relieving cushions that were not labelled for individual use were found to be soiled, posing a risk of cross-contamination. Additionally, one person had protective covers over their bed rails that were cracked and damaged, creating a potential breeding ground for infection.

These issues indicated that while general cleanliness was well managed, some aspects of equipment maintenance and infection control required improvement.

The systems in place for the management and recording of medicines needed improving. Staff did not consistently document the removal and reapplication of transdermal patch medications, including the rotation of application sites. This meant there was limited assurance that skin sensitivity and irritation were being effectively prevented, or that patches were being applied as prescribed.

Some topical creams stored in people’s bedrooms were found without opening dates on the packaging, making it difficult for staff to determine whether the products were still within their safe usage period.

There were also inconsistencies in the recording of medicines on MAR (Medication Administration Records) where codes used did not always align with the key, particularly when medicines were not administered or had been refused. Furthermore, when medication errors occurred, there was not always evidence of effective follow-up or learning to prevent recurrence.