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Inspection on 16/06/08 for The Old Rectory

Also see our care home review for The Old Rectory for more information

This inspection was carried out on 16th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People are provided with written information about the home and can visit to see if it`s the right place for them. People are assessed by a professional and by the manager of this home so that a decision can be made on whether the home can meet their needs.People said the following about the staff "they are kind and supportive and they help me in the way I want them to". People are encouraged to maintain contact with their friends and family who can visit them in the home when they want. People said they liked the food in this home and confirmed that they have a choice about what they eat. People said they are supported with respect and dignity, and liked living in this home.

What has improved since the last inspection?

The provider has addressed 2 of the 5 requirements from the previous report and has taken on board and implemented 7 out of the 20 recommendations. In relation to the requirements the provider has: Implemented a quality assurance system in order to obtain feedback about their service from people and their representatives who live in the service. A training programme is in place to ensure all staff undertake mandatory training to enable them to fulfil their roles.

What the care home could do better:

The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people All people that use this service on a temporary or permanent basis need to have a person centred plan developed to enable the staff to deliver care that is accordance with their needs and preferences. Each person must also have risk assessments completed to guide staff on how to support their healthcare needs and minimise any risks to the individual. The staff who administer medication should be observed and a written assessment completed to ensure they can safely administer medication in accordance with the policies and procedures in place. New guidance has been released about the storage of controlled medication in care homes. Therefore this service will need to take the required action to ensure they comply with the new regulations to ensure medication is stored safely. The recording of complaints needs to be improved to ensure that a written record is available to support the outcome of the complaint and to evidence that peoples concerns are being listened to. A programme of renewal needs to be developed with timescales so that we can monitor when areas of the building will be upgraded in order to provide a homely, and well maintained environment for people to enjoy.All of the required recruitment information must be obtained before staff commence employment in the home, this is ensure people who live in the home are safeguarded.

CARE HOMES FOR OLDER PEOPLE Old Rectory, The The Old Rectory Care Home 70 Risley Lane Breaston Derby DE72 3AU Lead Inspector Claire Williams Unannounced Inspection 16th June 2008 09:30 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 Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 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. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Rectory, The Address The Old Rectory Care Home 70 Risley Lane Breaston Derby DE72 3AU 01332 874342 01332 873826 asheathuk@yahoo.co.uk 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) Mr Allen William Heath Vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd July 2007 Brief Description of the Service: The Old Rectory is a detached property situated in the village of Breaston. It is situated 300/400 yards from the village centre and from a main bus route. The Service is registered to provide personal care for 26 older people of either gender. There are both single rooms and double rooms available on the ground and first floors. The first floor rooms can be accessed by both a shaft lift and stair lift. The home has five small lounge areas that can be used for a variety of different purposes; one is used as a hairdressing room. The home operates a no smoking policy. Information provided at this visit stated that the scale of fees was £325 - £395 per week. Information provided in the Statement of purpose and Service user guide indicates what this includes. Inspection reports are were available upon request from the provider. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is 1 star. This means the people who use the service experience adequate quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the service’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of 9 hours. In order to prepare for this visit we looked at all the information that we have received, or asked for, since the last key inspection on the 2nd July 2007. This included: • The annual quality assurance assessment (AQAA). This is a selfassessment that focuses on how well outcomes are being met for people using the service. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection report. • Completed surveys from people living at the home, staff, relatives and professionals that visit. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of three people’s files representing a cross section of the care needs of individuals within the home. Discussions were held with those individuals as able, and observations were made of the interactions between the staff and the people who live in this service. Individuals care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. What the service does well: People are provided with written information about the home and can visit to see if it’s the right place for them. People are assessed by a professional and by the manager of this home so that a decision can be made on whether the home can meet their needs. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 6 People said the following about the staff “they are kind and supportive and they help me in the way I want them to”. People are encouraged to maintain contact with their friends and family who can visit them in the home when they want. People said they liked the food in this home and confirmed that they have a choice about what they eat. People said they are supported with respect and dignity, and liked living in this home. What has improved since the last inspection? What they could do better: The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people All people that use this service on a temporary or permanent basis need to have a person centred plan developed to enable the staff to deliver care that is accordance with their needs and preferences. Each person must also have risk assessments completed to guide staff on how to support their healthcare needs and minimise any risks to the individual. The staff who administer medication should be observed and a written assessment completed to ensure they can safely administer medication in accordance with the policies and procedures in place. New guidance has been released about the storage of controlled medication in care homes. Therefore this service will need to take the required action to ensure they comply with the new regulations to ensure medication is stored safely. The recording of complaints needs to be improved to ensure that a written record is available to support the outcome of the complaint and to evidence that peoples concerns are being listened to. A programme of renewal needs to be developed with timescales so that we can monitor when areas of the building will be upgraded in order to provide a homely, and well maintained environment for people to enjoy. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 7 All of the required recruitment information must be obtained before staff commence employment in the home, this is ensure people who live in the home are safeguarded. 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 summary of this inspection report can be made available in other formats on request. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 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 Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 1, 3, 4 and 5 (standard 6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples needs are fully assessed prior to admission so the individual and the home can be sure the placement is appropriate. EVIDENCE: In the self-assessment completed by the provider they said they assess potential people either inside the home or at their placement. People are provided with a statement of purpose and service user guide when they move into the service. It was reported that these are also in peoples bedrooms. These documents contained all of the information that was necessary to inform people about the service provided, and it included comments from people that currently live in the service. This document needs to be updated to reflect the manager’s position as vacant and to include the new contact details of the Commission for Social Care Inspection (CSCI). Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 10 It was reported that prospective people were encouraged to come for a short stay prior to making a decision about whether the home will meet their needs. A person recently admitted to the home for respite care was spoken with and said that, “so far so good im having a nice rest”. We looked at three peoples files and they contained copies of assessments carried out by Social Services care managers. These were detailed and included information concerning each persons health and personal care needs, social interests, and relevant history. This provides staff with basic knowledge about people, and assists them to develop a personal service plan. The home does not provide intermediate care and there was no residents accommodated at the time of the site visit with diverse cultural or religious needs. It would be beneficial however for all documentation to be reviewed considering the six areas of diversity. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs were not being met due to the lack of care plans and safe medication systems being in place. EVIDENCE: In the self-assessment in the section of what they do well they said, “all aspects I believe”. In relation to the improvements in the last 12 months they said “employing a manager on trial”. They said their future improvements are “to continue training”. Out of the three files examined, two contained care records detailing peoples support needs and how these should be met. The care plans were written from the persons perspective and contained some information about their likes, dislikes, preferences, abilities and some information was recorded about their social history and background. However this information could be expanded and more detail provided to give more direction to the staff team on how individuals would like to receive their care. Information was in place concerning peoples 24 hour preferred routines. This enables the staff team to Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 12 gain more knowledge about the person and ensure they continue with their daily routines. The files had a combined risk assessment, which covered moving and handling, tissue viability, nutritional, and trips and falls. It requested for the staff to monitor the person in these areas. The support plans had a review date recorded but no other information was available to support if the plans continued to meet the person’s needs. There were records to support that people’s healthcare needs were being met and daily notes were recorded to support the well being of each person. The third file was for someone who was having a period of respite. The file contained the care manager’s need assessment and daily notes completed by staff, at this service, no other information was available. The person was staying for 2 weeks and had been in the home for 9 days. This file did not have any risk assessments completed on the person therefore the staff did not have any information about how the person mobilizes and whether they required support. This means that care staff did not have adequate information in order to meet this person needs. People spoken with said “im satisfied here they try their best”, “ the staff work hard and are very caring they help me when I need it”. Some relatives were spoken to and they said they were “satisfied with the care, everything seems to be ok”. People also said that staff supported them in a respectful and dignified manner. Medication in the home was stored securely in a locked cabinet, however when the medication was taken out to administer, the staff member had to carry the cassette boxes which were then placed in the kitchen area which is were they remained until the cook who is also a senior carer was responsible for administering the medication. The cassette boxes were placed on the table in the hallway while the medication was administered in the lounge. This means that the medication was not stored safely as it was left unattended for a period of time. Medication pots were not observed as being used by the staff member, who used her fingers to remove the medication in order to hand it to the person it was prescribed for. This is not in accordance with good practice. The medication administration records were seen and this indicated that people received their medication as prescribed. It was reported that staff had undertaken medication training and certificates of this training were seen. Staff had not had an assessment of their competency to administer training completed to ensure safe practices were followed. There was no controlled drugs being used at the time of the inspection visit, and information was provided about the new guidance about storage of this medication. Medication that required cold storage was locked in a tin and stored in the fridge, which is located in the kitchen area. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 12, 13, 14, and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were satisfied with the meals provided, but not all people have access to a varied and stimulating range of activities that meet their needs and preferences. EVIDENCE: In the self-assessment in the section of what they do well they said, “all people to fit into homes routines when they choose”. They said they have improved by “providing more social events”, and they said that the future improvements include “to introduce more activities, and buy more games”. A notice detailing the weekly planned activities was displayed in the corridor area. Today’s planned activity was bingo however this activity was not facilitated and some individuals participated in a ball game which involved throwing a ball into a net. A staff member that started employment in the service the day before facilitated this activity independently. Observations supported that no activities were available for individuals with high support needs and these individuals had no interaction with the staff apart from to complete daily task such as having a meal or being supported with their personal care. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 14 The staff members are responsible for facilitating activities on a daily basis in the afternoon when all other tasks have been completed. However due to completing other tasks limited time is available for activities. Feedback provided from the 2 surveys completed by people indicated that ‘occasionally’ there are activities that they could take part in due to their disabilities. A survey completed by a relative stated that it would be nice if people could go out on a trip occasionally. A record of activities offered was not available but there were some entries about people participating in activities in individual’s daily notes. People said they choose how they wish to spend their day and their choices and routines are respected. One person said “I get up when I want and go to bed when I want and I choose what I do in between” Individuals were observed reading books, as there is a small library available, or a newspaper and one individual spent some time sitting in the garden. The radio was on during most of day and on one occasion this was turned off without people being consulted. One individual said “what a relief with that off”, but the music was then changed and turned on again. We joined people for their lunchtime meal. There were no menus available as it was reported that these were currently being reviewed following consultation with people. There was no written information available about what the menu was for that day and what choices were available. There was no written information in the kitchen concerning people’s dietary needs, and it was reported that the staff “know what these are”. People said that choices were available and this was confirmed as two meals were provided for people. One person required support to eat their meal, and this was provided by a staff member who stood up whilst assisting with this task, which did not maintain this persons dignity. Another individual with high support needs kept wandering away from their meal, and although they was supported back to the table, support was not provided to encourage the person to eat their meal while it was hot. It was reported that due to problems with employing a designated cook, the care staff are now responsible on a rota basis to cook meals. Therefore a senior care assistant was responsible for cooking the main meal. There was evidence in this persons file to support that she had received training in safe food handling and the staff member confirmed this. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 16, and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were protected by the safeguarding procedures in place, but complaints are not responded to in accordance with the procedure, which could compromise people’s rights. EVIDENCE: In the self-assessment in the section of what they do well the provider said, “we address comments quickly”. They said they have improved by “the implementation of a bruising/incident file”. They intend to improve by “using a resident questionnaire”. People spoken with are aware of the complaints procedure and this was displayed in the home and was contained in the Service user guide. People said, “I would just go to the top to discuss my concerns”. Relatives spoken to also commented that they would speak with staff or the provider, as he was present in the home on a regular basis. The information provided to us stated that there had been one complaint made since our last visit, but when we examined the complaint book there were five complaints recorded. The records of complaints was not completed in full for all complaints received. This means that outcomes were not available to support that all complaints had been responded to appropriately. There was no written evidence to support that the last complaint has been responded to, Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 16 however it was reported that verbal response had been provided. These issues were raised in the previous report, and a requirement was made. In the improvement plan we received it stated that all complaints would be recorded in full and a date of the resolution would be recorded. However on this visit we found that this was not the case and therefore this requirement has not been met. It was reported that the local multi- agency safeguarding procedures were not in place and that staff had received updated training in this areas. The certificates in place and the discussions with the staff team confirmed this. The internal policy on abuse was examined, but this referred to bullying rather than abuse and did not specify the procedure for the staff should follow in the event of witnessing any potentially abusive incidents. However in discussions with the staff team, they demonstrated that they had a good understanding of what action to take if they witnessed a potential abusive situation. There has been one safeguarding referral since our last visit and this was responded to in accordance with the local procedures. People spoken to said they felt safe living in this home. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 19, 20, 21, 23, and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are required to ensure people live in a homely and safe environment. EVIDENCE: In the self-assessment in the section of what they do well they said, “we provide personalised and comfortable environment”. They said they have improved by “included a lot of redecoration and art work on the walls”. They said they intend to improve further by “the replacement of carpets in communal areas”. A tour of the building was undertaken and several areas have been upgraded. It was reported that redecoration is taking place on a priority basis. However several areas still require attention and many of these areas were identified in the previous report. These include: Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 18 • • • • The stair carpet was worn and in need of replacement. This has been noted in every report since January 2005. Some furniture in bedrooms was in a poor state of repair. This has been noted in every report since January 2005. There was an odour in some bedrooms. A number of doors and wooden chairs were badly scratched. We asked to see the renewal programme but a written programme is not in place and it was reported that areas are upgraded when required. The improvement plan we received in response to the requirements raised about this stated that the areas we identified would be addressed within 2-3 months and this document was received on 28/11/07. However these areas have not been addressed, but as stated other areas have been upgraded. It was reported that the stair carpet was not a hazard as yet and that it would be replaced in 2 months time. People spoken to and the surveys reflected that individuals thought the environment was homely, safe and met their needs. There was evidence of equipment in place to aid individual’s mobility. A passenger lift is in place and this was reported to have broken down, however it was deemed to be safe for use with staff support and people were fine about this. It was identified that the staff toilet does not contain a washbasin. Staff were observed using the kitchen area to wash their hands or using a sink in the next room. We observed that communal nailbrushes were in place and this could lead to cross infection. The laundry is small in size which means staff have to fold clothing in communal areas. Comments made in the surveys indicated that clothing is often lost and never found or replaced. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 27, 28, 29, and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The recruitment and deployment of staff does not safeguard people and meet their needs. EVIDENCE: In the self-assessment the provider said in the section of what they do well; “use quality staff if no good then they replace them”. They said they have improved by “ensuring references and POVAs are in place”, and future improvements include “to try to retain the good quality staff they have”. At the time of this visit there was four care staff on duty, and this included two senior carers. The most experienced member of a staff was nominated to work in the kitchen to undertake the role of the cook. This then left one senior carer and two new staff; one of these staff members commenced employment five weeks prior and the second staff member commenced the day before our visit. It was reported that all new staff are supervised by a senior staff member during the first week of their employment, however observations supported that the staff member who commenced the day before was part of the allocated staff numbers and at times supported people independently and unsupervised. During discussions with these staff members they stated that they had not yet undertaken any formal training in the home, and this was confirmed as there Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 20 was no evidence to support that any training had been provided other than a service specific induction. An incident occurred during our visit and the new staff member was the first to attend the scene, when asked what the persons name, the staff member did not know, and we had to wait for a senior carer to attend to provide the emotional support and encouragement. The staff files for the newly appointed staff and a senior were examined. All three files did not contain the required information in order to safeguard people from risk. Examples of this include: • • • • Incomplete employment history Gaps in employment history Not all files contained two employment references Verification of employment not checked. There was evidence to support that existing staff have access to the mandatory training, and these were up to date. A system is in place for providing an induction programme, which linked in with a college but this means that new staff have to wait for the next in-take before they can commence their induction training. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is not managed in the best interest of the people due to the shortfalls in the care planning, recruitment practices, and management arrangements, which do not safeguard people. EVIDENCE: In the self-assessment we received in the section of what they do well they said, “they bring up to date all of the care records”. They said they have improved in the last 12 months by “the introduction of an acting manager (previously deputy at other service)”. They said the future improvements include “a care co-ordination with the acting manager”. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 22 The provider currently manages the service and as stated an acting manager is now in place. The service has been without a manager for a period of time, which has had some impact on the staff and the people who live here as in discussions they were unsure who the person in charge was other than the provider. The staff rota’s were not clear in respect of what the staff roles were and it was difficult to identity who the acting manager was and when she was on duty. A colour code system was in use to identity what tasks the staff had to undertake on that particular shift and different staff were nominated as the person in charge instead of this consistently being the acting manager. There were a number of ways that the people are encouraged to comment on the service. An annual quality assurance survey has now been developed and the first survey is to be distributed in the next month. This refers to the food provided as the menus have been reviewed and changed and feedback is required to ensure people are happy with the new options in place. Informal discussions are held with people to ensure the service is meeting their needs, and there is a suggestion box in the reception area. It was reported that a supervision structure has not yet been developed and the provider is currently responsible for facilitating these. Although there was some evidence of supervision being undertaken this was not in accordance with the required frequency. Information provided was that regular health and safety checks were being done. This included testing call systems and fire equipment. Accident and incident forms were completed but no action recorded to reduce risk of further accidents including falls by individuals. During the tour of the building cleaning fluid was observed to have been left in a communal area, and this was removed immediately. Several toiletries named and un-named were also observed in the bathrooms areas which is not good infection control practices or in accordance with maintaining a persons dignity, as all toiletries should be named and returned to the persons bedroom. The management of people’s money was examined and transactions sheets were in place. All people’s money continues to be polled together in one large sum, which is not good practice. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 23 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 3 X 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X 3 X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) Schedule 3 (2) Requirement Timescale for action 01/09/08 2. OP8 17 (1) (a) 3. OP9 13 (2) 4. OP9 13 (2) Peron centred plans, and a photograph must be in place for everyone living at the home, including new people and people staying for respite care. This is to ensure that staff are aware of peoples needs and wishes in order to provide good quality care. Health care plans and risk 01/09/08 assessments must be in place for everyone living at the home, including new people and people staying for respite care. This is to ensure that staff are aware of peoples healthcare needs and wishes in order to provide good quality care. Medication must be stored and 01/09/08 administered in accordance with the pharmaceutical guidance and code of practice. This includes the new guidance referring to storage of controlled drugs. This is to ensure people receive their medication safely All staff that administer 01/09/08 medication must have an assessment undertaken after DS0000033891.V366855.R01.S.doc Version 5.2 Old Rectory, The Page 25 5. OP12 16 (2) (n) 6. OP16 22 (3), (4) & (8) 7. OP19 23 (2) (b) 8. OP26 16 (2) (j) 9. OP27 18 (1) (a) 10. OP27 Schedule 4 (6) (e) they have received training to ensure they are competent to administer medication to people safely Activities must be available and inclusive to all people that live in the service. This is to ensure people have access to recreational activities that meet their needs and preferences. A full summary of complaints and the action taken to resolve them must be available to ensure they have been responded to appropriately Repeated from the previous report as not met – previous timescale - 01/09/07 A programme of renewal must be developed with achievable timescales to state when certain areas will be upgraded and replaced or repaired. This is to ensure that people live in a safe and homely environment Previous timescales for work to be completed have not been met. Systems and facilities must be available to enable the staff and people to wash their hands and maintain safe hygiene practices. The deployment of staff must be reviewed. This review needs to take into account the number of people living at the home and their dependency levels, and respite and time for activities as well as the number of hours care staff undertake domestic duties. This is to ensure that people’s needs are being met at all times. The duty roster must include staff member’s full names and their deployment in the service. This is to ensure that they clearly identify who is working in the service and their position. DS0000033891.V366855.R01.S.doc 01/09/08 01/09/08 01/10/08 01/09/08 01/09/08 01/09/08 Old Rectory, The Version 5.2 Page 26 11. OP29 19 (1) & Schedule 2 12. OP30 18 (1) (c) (i) All staff employed must all of the required recruitment checks and information available on file and for inspection to ensure legal requirements are met and people safeguarded. (Previous timescales of 30/08/05 and 30/06/06 / 05/07/07 not met. All staff must access training in Mental capacity Act to enable them to promote peoples rights. 01/08/08 01/09/08 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 statement of purpose and service user guides should be amended to include fees and the up-to-date address and telephone number of CSCI so that people have the correct information. The admission records should be reviewed to incorporate the following areas of diversity: race, gender identity, disability, sexual orientation, age, religion and belief. These areas should be completed for each resident. Care planning records should hold comprehensive information on social history and individual preferences and dietary requirements to ensure it is person centred. A designated activities co-coordinator should be appointed to ensure activities are inclusive and provided to all people who live in this service. Staff should remain sitting when supporting a person to eat their food in order to maintain their dignity. A copy of the local multi- agency safeguarding procedures should be obtained and kept in the service for staff to refer to. All new staff should be supervised by an experienced member of staff until they have completed their induction. The acting manager should process her application to DS0000033891.V366855.R01.S.doc Version 5.2 Page 27 2. OP3 3. 4. 5. 6. 7. 8. OP7 OP12 OP15 OP18 OP30 OP31 Old Rectory, The 9. 10. OP35 OP38 Commission for Social Care Inspection as soon as possible to ensure she is fit for purpose to managed the service. People’s money should be held separately and not pooled together into one large sum. Cleaning fluids and toiletries should be stored away safely when not in use. This is to ensure the environment is safe for people to enjoy and to maintain peoples dignity. Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Old Rectory, The DS0000033891.V366855.R01.S.doc Version 5.2 Page 29 - 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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