Inspection on 26/01/06 for The Old Deanery

This inspection was carried out on 26th January 2006.

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

The Old Deanery 03/06/09

The Old Deanery 20/05/07

The Old Deanery 24/06/05

The Old Deanery 17/02/05

The Old Deanery 12/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Old Deanery Deanery Hill Bocking Braintree Essex CM7 5SR Lead Inspector Kay Mehrtens Final Unannounced Inspection 26th January 2006 12.00 X10015.doc Version 1.40 Page 1 X10015.doc Version 1.40 Page 2 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 The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 3 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. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Name of service The Old Deanery Address Deanery Hill Bocking Braintree Essex CM7 5SR 01376 328600 01376 344278 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) Anglia Retirement Homes Limited Mr Clive Ansell-Jones Care Home 70 Category(ies) of Old age, not falling within any other category registration, with number (70) of places The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 5 SERVICE INFORMATION Conditions of registration: 1. Old age, not falling within any other category (not to exceed 70 persons) 24th June 2005 Date of last inspection Brief Description of the Service: The Old Deanery comprises of a large listed building, with a new extension built in August 2000. The home is on two floors and offers single bedroom accommodation, with the exception of one companion room. The majority of bedrooms have en suite facilities. The home offers accommodation to seventy service users who are aged 65 and over. The home is set in large well maintained gardens with an enclosed courtyard provided. Car parking is available and security gates are provided at the entrance to the home. The Old Deanery is situated in the village of Bocking, which is within easy reach of the town of Braintree and surrounding facilities. There is furnished accommodation, for independent living, in a two bed roomed flat on the third floor. Clear criteria are set with regard the tenancy and a separate contract states that tenants access to the home is limited to flat access only, unless invited to visit. Tenants only receive housekeeping provision. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 26th January 2006, lasting 2.5 hours. This was the second statutory inspection of the year and focussed on the remaining key standards not inspected at the last inspection, as well as a review of the requirements and recommendations from the last inspection. The inspection process included: discussions with the deputy manager, registered provider, care staff, residents; a visiting doctor and the information gathered from a pre-inspection questionnaire sent to the manager. There were 67 residents accommodated at the time of the inspection. The premises were inspected, including the grounds. Samples of records and residents care plans were inspected. The inspection covered six standards, one of which exceeded the standard. The home was clean and maintained to a very high standard. The staff were caring and much respected by the residents. A visiting doctor told the inspector that in their opinion “the care is good. Good information is provided and they are not kept waiting.” What the service does well: What has improved since the last inspection? The new wooden flooring in the corridors, hallways and some bedrooms are worth mention, as they look lovely. The new flooring is much appreciated by residents as they find it easier to manoeuvre their wheelchairs and frames. The staff rota and task allocation had improved and ensured that here was sufficient staff to meet the needs of residents, especially at mealtimes. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 7 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. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 8 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 The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 9 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): Standard 6 is not applicable EVIDENCE: These standards were not inspected at this inspection. The Old Deanery DS0000017972.V280740.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 Care plans provided enough information to assist staff in meeting the needs of residents. EVIDENCE: Only one care plan that of a recently admitted residents was sampled. The preadmission assessment was completed by the manager and covered all the required aspects of care needs. The information was gathered from the resident and their family. The file contained appropriate risk assessments and action plans with regard to mobility, as identified from the assessment documents. The care plan was detailed and addresses all the identified care needs of the resident concerned. There was good evidence of clear actions for staff to meet the identified needs of the resident and so ensure consistency of care. There was evidence of manual handling assessment though it was not dated. There were other relevant risk assessments, identified as part of the assessment process. There was no evidence of any input by the resident into their care plan as no signature had been sought. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 11 Residents are supported should they wish to self-administer their medication. However, there was no evidence of any consent to medication administration on the care file though a member had staff had written, “would like staff to look after their medication”. The Old Deanery DS0000017972.V280740.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): 15 Residents are provided with a balanced diet. EVIDENCE: Residents are offered a choice of meals, from an alternative menu, should they not like the daily meal. They were generally very complimentary regarding the meal served on the day of the inspection. Residents were provided with drinks and snacks at appropriate times of the day and on request. There was evidence of drinks provided in residents’ bedrooms. The home has two downstairs dining areas and an alternative dining area, on the first floor, which is generally used by residents when entertaining relatives or friends. All the dining rooms are pleasantly decorated. The inspector arrived at lunchtime so as to observe the mealtime arrangements following comments and recommendations, from the last inspection, about the difference in the standards of dining experience for residents. Lunch was served in two sittings. At the first, twelve o’clock sitting, the larger dining room was set for dinner. There were tablecloths and a selection of water, sherry and wine glasses provided. There were two staff in attendance. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 13 Residents were offered sherry and a choice of wine. Vegetables were served from tureens and residents choose what and how much they wished to eat. The atmosphere was very sociable. The other, smaller dining area was very busy with lots of residents and four care staff. There were no tablecloths and no selection of glasses. The staff were not even sure if residents were offered sherry as a normal practice. Residents’ meals were plated up and put in front of them and so gave them little opportunity to exercise choice. This dining area seemed to accommodate those residents that required assistance with eating or were a little confused. Staff were observed to use footstools and kneel next to residents that needed assistance. They told the inspector that there was not sufficient space for more chairs. This is not good practice. The room was overcrowded and residents were deprived of an opportunity to have quality 1 to 1 time with staff. The second sitting was at about 1.20pm. The larger dining room had only five residents using it and the smaller room had seven residents, all enjoying their meals. Staff were still using footstools when assisting residents in the smaller dining room even though there was plenty of chairs to use. Sherry was provided for residents in the larger room out of a full decanter and there was evidence of a selection of wine glasses on the tables. Though in the small dining room there was only an empty sherry bottle and no evidence of any sherry or wine glasses on any tables. The staff expressed concern about serving residents alcohol in case they were on medication. This did not appear to be a general concern for all residents only those that were not able to express an opinion. The inspector advised the deputy manager to check with the pharmacist as to any possible interactions and then discuss with residents and or their representatives so that their rights are respected. The inspection has again highlighted the difference in the dining experience for residents that use the smaller dining room and who tend to be more confused and in need of more assistance. The use of two sittings does not seem to offer a better experience for residents in the smaller room and does not appear to be effectively used to ensure a sociable use of space and a pleasant and equitable dining experience for all residents. The inspector brought this to the attention of the provider and deputy manager. They assured the inspector that it would be addressed. The Old Deanery DS0000017972.V280740.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): EVIDENCE: These standards were not inspected at this inspection. The Old Deanery DS0000017972.V280740.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): 19 The standard of the environment is excellent and exceeds the standard. The home provides the residents with a safe, comfortable and pleasant environment. EVIDENCE: The premises were not fully inspected as this was achieved at the last inspection. However, the home has had several improvements and changes since then and these were inspected. One of the downstairs small lounges has been fitted and equipped for small activities such as crafts, computer, music and games. This was seen to be a room much enjoyed by the residents. It was lovely to see residents’ work and events displayed. Other improvements included the replacement of more corridor floors, as well as some residents’ bedrooms, with non-slip wooden flooring. The premises were, as usual, maintained and decorated to a very high standard. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 16 The Old Deanery DS0000017972.V280740.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): 27 Staffing levels are reviewed to ensure that they meet the needs of the residents. Staffing levels are sufficient to meet the needs of the residents. EVIDENCE: The staff rota showed that two seniors and six care staff are employed throughout the day. The staff are allocated to each floor and to different tasks throughout the day. The deputy manager is generally in addition to staffing levels but was working “on the floor” on the day of inspection. The use of agency staff is very low and so residents benefit from a stable staff group. The staff were observed to interact with residents in a respectful and pleasant manner. The inspector was impressed by the busy yet gentle activities taking place in the newly furbished activity room. The residents were clearly enjoying the different activities on offer. The displays and music made the room a very inviting place for activity and social interaction. The inspector had the opportunity to meet a visiting doctor. They commented positively regarding the care provided at the home. They received good information and felt that referrals were appropriate. They appreciated the quick response to visits. By the staff on duty, so that delays in attending residents was minimal. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 18 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): 33 The manager is well supported by the owner and staff in providing a well managed home that ensures good care for the residents. EVIDENCE: The deputy manager did forward a copy of the most recent satisfaction survey from residents and relatives. It indicated a high level of satisfaction of the care and services provided at the home. However, this standard was not fully inspected at this inspection and will be monitored at the next inspection. The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 19 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 4 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 X X X X X X X X The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 20 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. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that residents are involved in their care plans and evidence their input and consent to medication administration. Timescale for action 20/03/06 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 OP1 Good Practice Recommendations The registered person should include the views of service users, regarding the home and care provided, in the Service Users Guide. This was not fully inspected and will be monitored at the next inspection. The registered person should ensure that the level of service and staff assistance is the same in both dining areas for each mealtime sitting. This was raised at the last inspection. 2. OP15 The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 The Old Deanery DS0000017972.V280740.R01.S.doc Version 5.1 Page 22 - 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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