Inspection on 10/11/05 for The Old Rectory

This inspection was carried out on 10th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Old Rectory 23/07/09

The Old Rectory 30/04/09

The Old Rectory 03/05/07

The Old Rectory 26/04/06

The Old Rectory 27/06/05

The Old Rectory 23/11/04

The Old Rectory 26/06/04

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

CARE HOMES FOR OLDER PEOPLE The Old Rectory Church Street Tenbury Wells Worcestershire WR15 8BP Lead Inspector R McGorman Unannounced Inspection 10th November 2005 10:30 X10015.doc Version 1.40 Page 1 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 Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 2 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 Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address Church Street Tenbury Wells Worcestershire WR15 8BP 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) 01584 810249 01584 810249 Chantry Retirement Homes Ltd Mrs Annette Elizabeth Cooper Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (28) The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate one named person under the age of 65 who has both a learning disability and physical disability. 27th June 2005 Date of last inspection Brief Description of the Service: The Old Rectory is registered to provide residential care for up to twenty-eight older people who are frail, who may have a physical disability or who may have mental health problems. Respite care can be provided when a bed is available and in addition two-day care places can be provided. The Old Rectory is an imposing listed building dating back to 1830. Previously a rectory, it is situated within 100 yards of St Mary’s Parish Church and it is also in close proximity to the centre of Tenbury Wells. The stated aim of the Home is to provide a consistently high standard of professional care, in order that service users can live as normally as possible, and where their individuality, independence and dignity are respected and upheld. The home was purchased by Chantry Retirement Homes Limited, in March 2004, and the directors are Mr Sefudin Hussein and Mrs Tasnim Ghiawadwala. The Registered Manager, Mrs Annette Cooper, has many years experience of working with older people, is responsible for the day to day running of the home. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine, unannounced inspection, was to check on previous requirements and recommendations, and to monitor care provision at the home. The Care Manager Mrs Annette Cooper, who has been registered recently, and the Proprietor, Mr Sefudin Hussein, were both present during the inspection, and time was spent discussing the present situation at The Old Rectory, and also future proposals. Service users and staff were consulted about their experiences of living and working at the home, and every one was very positive in their comments. Visitors and professionals who were spoken with, at the home, on the day of the inspection also expressed their satisfaction with the care provided. A tour of the premises was undertaken, and the records kept in respect of the maintenance of equipment and safe working practices, including the fire log book, were also checked during the course of the inspection. The care records of several residents were seen, and the files of some staff were inspected. What the service does well: The impression gained is that the home is well maintained and cared for, and that it is comfortable and secure. A warm welcome is given to everyone, on arrival at The Old Rectory. There is a calm and relaxed atmosphere, where mutual respect and consideration are constantly in evidence. The approach of staff is very obviously caring, which is what they consider they are good at, and this was clearly confirmed by service users, their families, and visitors to the home, with very positive comments being made, by everyone. Activities feature very highly at the home, with in-house and community based opportunities available. Regular trips out in the minibus are very much appreciated. A co-ordinator is also employed, specifically to organise the various past-times. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 Rectory DS0000052033.V260964.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 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 the following standard(s): 1,2 & 6 The Statement of Purpose, and Service Users Guide, provide information about the home, to enable a prospective service user to make an informed decision about their future care needs, although the format should be further developed. EVIDENCE: The Statement of Purpose has been amended to include the information required by this standard, although the format still needs to be improved. A Service Users’ Guide, in the form of an information booklet provides some additional information about the home for prospective service users. Copies of these documents are to be submitted to the Commission on completion. The statement of the Terms and Conditions of Residence has been updated and amended, and now contains relevant details. Intermediate care is not provided at The Old Rectory. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 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 the following standard(s): 7,9 & 11 An individual plan of care for each resident is maintained, and contains relevant information, which ensures that the needs of service users are met appropriately. Policies for the safe administration of medication are in place, although the correct procedures had not been followed recently, which has seriously compromised the safety of service users. Procedures are in place for managing the death of a service user, to ensure that their dignity is maintained and their wishes respected, and the training planned for staff will increase their understanding of the related issues. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 10 EVIDENCE: The registered care manager has been developing the individual care plans, and several were checked during the inspection. Further improvements are evident, although the content could be more detailed, and greater involvement encouraged from the service user and their family. The plan of care should be signed by the service user, or a representative, to indicate their agreement with the contents. The daily log is being completed to a satisfactory standard. A previous visit to the home by the Pharmacist Inspector confirmed that significant improvements had been made in the control and handling of medication. These standards have been maintained until recently, when a serious administration error made by a senior carer, demonstrated that the procedures are not being followed. A further visit to the home has since been made by the Pharmacist Inspector, and Immediate Requirements made, as serious concerns were noted in several areas relating to the administration of medication. There have been several service users who have died at the home during recent months, and staff have been able to offer appropriate care during the final stages of their life, with the support of the Primary Health Care Team and Marie Curie Nurses. A bereavement counsellor is also available at the local hospital. The wishes of the service users and their family, regarding terminal care and arrangements after death, are included in their records. There has been no specific training for staff in dealing with the service user who is dying, or families who are grieving, but this is now planned for January. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 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 the following standard(s): 12,14 & 15 Service users have complete freedom in regard to their contacts, both within and outside the home. Their wishes and preferences are respected, and they are encouraged to make choices about all the activities of daily living, which enables a good quality of life to be maintained. Service users are offered a choice of nutritious and wholesome and wellbalanced meals. A record of the food provided to each service user is now maintained, therefore it is possible to ensure if a satisfactory diet is taken by everyone. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 12 EVIDENCE: Service users confirmed they are able to choose how they spend their time. Various activities are available both within and outside the home, although some people prefer to stay quietly in their own room. The home employs an activities organiser, who was supervising a ‘knitternatter’ reminiscence session on the day of the inspection. The home has a minibus to take the more adventurous a little further from home, and they visit various places of interest or just go for a ride. The spiritual needs of service users are considered. A monthly service is held at the Home, and residents are able to attend church, if they wish. The daily menu was posted on the notice board, and the four-week menu plan indicated that a good variety of food was available. Special dietary requirements can be provided and currently includes 3 diabetic diets. Many favourable comments were made by service users regarding the standard of the food at the home. A record of the food provided to individual service users is now being maintained at the home. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 13 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): 16 & 18 A record of all complaints should be maintained, in order to provide evidence that all concerns are responded to appropriately. The absence of appropriate policies and procedures relating to the Protection of Vulnerable Adults is placing service users at possible risk of harm or abuse. EVIDENCE: A satisfactory complaints procedure has been produced and is accessible to service users and their families, although a record of complaints, comments and compliments should be maintained. There have been no recent complaints made to the home or to the Commission. The policy and procedure on adult protection at The Old Rectory, has been amended to reflect the change of management of the home. A copy should now be submitted to the Commission. The Protection of Vulnerable Adults (POVA) guidance, in relation to staff who may be unsuitable to work with vulnerable people, has not yet been implemented at the home, therefore this should be undertaken without further delay, and a copy of the procedure submitted to the Commission. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 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 the following standard(s): 19,23,25 & 26 The premises are suitable for their purpose. The building is well maintained, the standard of cleanliness is satisfactory, and the décor and furnishings are in good condition, providing a very comfortable and homely environment for service users. The safety of service users and staff continues to be compromised by the failure of the Proprietor to ensure that the radiators and pipe work throughout the home are guarded. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 15 EVIDENCE: The Old Rectory is located in a quiet area of Tenbury Wells, with easy access to the town centre. The house was converted into a residential home in 1985, and has been developed and upgraded to provide comfortable and wellmaintained accommodation. The grounds, although not extensive, are accessible to residents. There are two pleasant lounges situated on the ground floor, and a large dining room. The communal areas of the home are furnished and decorated to a high standard, and a maintenance programme is in place. There are five bedrooms large enough for double occupancy, although two are being used as single rooms. Agreement has been reached with the Proprietor that this arrangement will continue, although consideration should be given to reducing the number of shared rooms. Service users in double rooms have made a positive choice to share with each other, and a record is kept of this arrangement in their individual care plans. Service users bedrooms are well ventilated and centrally heated, with each radiator having an individual thermostat, but guarding of the pipe work/radiators has not yet been completed. The Proprietor confirmed that this work will be undertaken within the next 2 months. The home has not received a recent visit from the Environmental Health Officer. The manager has been in contact following an accident sustained by a member of staff earlier in September, and a visit is anticipated in the near future. The Home is clean and odour free, and an infection control policy is in place. Protective clothing is provided, and staff are given training in health and safety matters. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 16 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): 27,29 & 30 Staffing levels are being maintained at an adequate minimum level to meet the needs of service users. Improved recruitment procedures are in place, which should ensure the protection of service users. Training has been provided, but the formal training programme for staff is not sufficiently developed to ensure that each member of staff is competent, and has a clear understanding of their role, and therefore able to deliver care appropriately. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 17 EVIDENCE: The changes in the ownership and management arrangements at The Old Rectory, initially created some disruption in the staffing situation, and several staff subsequently resigned. The situation is becoming more stable, but should continue to be closely monitored to ensure that staffing levels reflect the identified needs of service users. Changes to the staff rotas are proposed, with the introduction of split shifts, to provide additional staff during the busier times of the day. The management of the home should also ensure that a senior member of staff is on duty at all times, throughout the twenty-four hour period. Recruitment procedures have been improved, and staff files indicate that the relevant documentation is now in place. The application form has been amended, and requires the appropriate information to be submitted. Training has been provided in Abuse Awareness, Moving & Handling, Drug Awareness, Infection Control, and Basic First Aid, and further training has been arranged in Basic Food Hygiene and Care of the Dying. The need for a review of the training needs of each member of staff, and development of an individual training and development profile has again been identified. Further training for staff with responsibility for administering medication must be arranged without delay. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 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): 31,32,33,34,35,37 & 38 The management arrangements at the home are satisfactory, and the residents and staff benefit from the positive approach of an experienced manager. Development of the quality assurance system will enable the views and opinions of service users to have a greater influence in how the home is run. Suitable accounting procedures are in place to ensure satisfactory management of the business, and the financial procedures safeguard the interests of service users. The interests of service users and staff are not safeguarded by the absence of appropriate risk assessment in respect of all safe working practices. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 19 EVIDENCE: Mrs Annette Cooper is the Registered Care Manager at The Old Rectory, with responsibility for the day-to-day management of the home. She has been employed at the home for approximately 9 months, and has many years experience in the nursing profession, and more recently in the management of nursing and residential care homes. She is an NVQ Assessor, and has also commenced the Registered Managers Award. Comments from service users, their families and staff working at the home, have been very positive regarding Mrs Cooper being approachable and supportive. Her leadership is obviously appreciated following a long period without a registered manager. A quality monitoring system has not yet been introduced at The Old Rectory. The manager confirmed that the project she is undertaking at College is related to the implementation of a quality assurance programme. Staff do not have the responsibility for managing the financial affairs of any service users. Verbal confirmation was received from the Proprietor in regard to the financial viability of the business, and an annual business and financial plan is to be submitted to the Commission. Appropriate insurance cover is provided, in respect of all aspects of the business. The records were not checked in detail during the inspection, although those seen had been completed to a satisfactory standard. Contracts are in place for the regular servicing and maintenance of equipment. The Fire Log indicated that weekly checks of the fire alarm system, and practice evacuations are undertaken. The advice of the Fire Safety Officer should be sought in regard to completion of the Fire Risk Assessment for the home. Risk assessments in respect of all safe working practices, also remain outstanding, and should now be undertaken without further delay. The Accident Books had been completed, although Regulation 37 Notifications had not always been made to the Commission, when appropriate. The Commission has not received a recent report on the conduct of the care home, from or on behalf of the Responsible Individual, in respect of the monthly visits to the home, under Regulation 26. The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 20 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 2 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X 3 X 2 3 STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 3 3 X 2 2 The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES 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 OP9 Regulation 13 Requirement With immediate effect the registered person must ensure that staff adhere to the procedures for the safe administration of medication A record must be kept of all complaints, and must include details of the investigation and any action taken. Exposed pipe-work and radiators in service users’ rooms must be guarded or have guaranteed low temperature surfaces (Timescale of 31/03/05 not met) A quality assurance system must be introduced in accordance with the requirements of Regulation 24 & Standard 33 (Timescale of 31/03/05 not met) Notification must be made to the Commission of the occurrence of all accidents, injuries, illness and incidents, in accordance with Regulation 37 and Standard 38. A written report of the monthly visits to the home, by or on behalf of the Registered Provider, must be prepared, and a copy sent to the Registered DS0000052033.V260964.R01.S.doc Timescale for action 30/11/05 2 OP16 17 & 22 31/12/05 3 OP25 23 31/12/05 4 OP33 24 31/12/05 5 OP38 37 30/11/05 6 OP38 26 31/12/05 The Old Rectory Version 5.0 Page 22 7 OP38 13 8 OP38 23 Manager, the Company and the Commission The health and safety of service users must be promoted by undertaking risk assessment in respect of all parts of the home to which service users have access, any activities in which service users participate and for all safe working practices (Timescale of 31/03/05 not met) The registered person must consult with the Fire Authority, and take adequate precautions against the risk of fire. A fire risk assessment must be developed 31/12/05 31/12/05 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 2 3 4 5 Refer to Standard OP1 OP4 OP7 OP18 OP18 Good Practice Recommendations The statement of purpose and service users guide should be produced in a suitable format, and copies submitted to the Commission A copy of the amended admission procedures should be sent to the Commission as requested previously The care plans should be more detailed and service users involved in drawing up and reviewing their plan of care A copy of the procedures for responding to suspicion or evidence of abuse should be submitted to the Commission as requested previously A procedure should be produced in relation to staff who may be unsuitable to work with vulnerable adults, and who may need to be considered for inclusion on the POVA register Consideration should be given to improving the ratio of single/double rooms within the home A copy of the training programme for staff should be submitted to the Commission when completed. An individual training and development assessment and DS0000052033.V260964.R01.S.doc Version 5.0 Page 23 6 7 8 OP23 OP30 OP30 The Old Rectory 9 OP34 profile should be provided for all staff A copy of the business and financial plan for the establishment should be submitted to the Commission The Old Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Rectory DS0000052033.V260964.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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