Inspection on 24/01/06 for The Old Rectory

This inspection was carried out on 24th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Rectory 05/12/06

The Old Rectory 26/09/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Old Rectory Sturton Road Saxilby Lincoln Lincs LN1 2PG Lead Inspector Elisabeth Pinder Unannounced Inspection 24th January 2006 09:00 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 DS0000064006.V279772.R01.S.doc Version 5.1 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 DS0000064006.V279772.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address Sturton Road Saxilby Lincoln Lincs LN1 2PG 01522 702346 01522 703508 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) M & M Care Ltd Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:Old Age, not falling within any other category (OP) (24) The maximum number of service users to be accommodated is (24) Date of last inspection 26th September 2005 Brief Description of the Service: The Old Rectory cares for older people in a non-smoking environment in a detached property situated on the edge of the village of Saxilby. The home is approximately five miles from the historic city of Lincoln. The property is a converted rectory and stands back from the road in it’s own grounds and gardens with car parking facilities to the rear of the building. The home has two floors and there is a stair lift to the bedrooms on the first floor. There is a variety of aids and adaptations around the building to allow residents to move around the home more independently. Eighteen of the bedrooms are single, three bedrooms have an en-suite toilet. There are 7 communal toilets and 3 communal bathroom/shower rooms. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4.5 hours and was carried out by one inspector as the 2nd of two statutory inspections for 2005/6. The main method of inspection used was “case tracking”. This involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. Two bedrooms were viewed and a selection of care records inspected. Prior to the inspection two relative/visitor comment cards were received. Specific comments written were; “The staff appear to be kind, caring and compassionate” and “since the home changed ownership there has been very poor lines of communication”. What the service does well: What has improved since the last inspection? What they could do better: Individual care plans must contain sufficient information to ensure that all aspects of health, personal and social care needs are identified and planned for. Daily contact records should contain appropriate detail and should not read ‘slept well’ or ‘remains fine’. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 6 Although an activity programme has been drawn up, staff and residents said that these are not always offered unless carried out by the activity co-ordinator who comes into the home once a week. Regular checks should be made and records kept of the temperature in the home and in resident’s bedrooms. All care staff must receive regular supervision. The Commission must be notified of all significant events which affect the wellbeing of residents. 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 DS0000064006.V279772.R01.S.doc Version 5.1 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 DS0000064006.V279772.R01.S.doc Version 5.1 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): Standard 3 was inspected during the previous inspection. Standard 6 is not applicable for this service. EVIDENCE: The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 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 Care plans are very basic and do not identify all the health and social care needs of residents and the action to be taken to meet those needs. These shortfalls have a potential to place residents at risk. EVIDENCE: Individual care plans are available but these do not contain sufficient information to ensure that all aspects of health, personal and social care needs are identified and planned for. This was highlighted during the previous inspection. However, due to a change in management this has not been addressed. Please also refer to the management standards. One resident said she is aware information is written about her but did not know what was written in her individual plan of care. Another resident spoke about her recent diagnosis of diabetes, however, there was very little information recorded about this or the action care staff need to take to ensure appropriate care is given. It was also noted that daily contact records for one resident frequently read ‘slept well’ or ‘remains fine’ and management are asked to ensure daily records contain more appropriate detail. The three care files examined did not contain a photograph of the resident and management are asked to address this. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 10 Currently there are no residents who self-administer their medication. However, polices and procedures are available should this change. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 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 Residents living in this home are helped to make choices and live their preferred lifestyle. However, planned activities should be available. EVIDENCE: Observations indicated that residents have a choice as to what they do at the home. For example, on the day, some residents were reading, some were watching television and others were in their own rooms. Another resident had gone out for a walk. Residents spoken to said that they are able to make their own choices regarding how to spend their day. Both residents and staff confirmed that meetings are held and day-to-day issues are discussed openly, the last meeting was held in November. The owner said that minutes were at her home and had not been typed yet. It is recommended that these are kept in the home. A further meeting is being planned where relatives will also be invited. During the previous inspection residents commented that they would like activities to be available more frequently and planned and an activity programme has been drawn up. However, staff and residents said that these are not always offered unless carried out by the activity co-ordinator who comes into the home once a week. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 12 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): Standard 16 & 18 were inspected during the previous inspection. EVIDENCE: The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 13 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): 26 This home is clean and tidy with a pleasant smell throughout the home. EVIDENCE: This home employs separate cleaning staff to undertake domestic duties and during the visit the home was clean, tidy and there were no unpleasant odours. Residents spoken to all said that they are very satisfied with the cleanliness of the home and of their personal bedrooms. One resident said how kind the cleaner is and how she has developed a friendship with her. Records of one resident indicated that she had been cold at night and this was discussed with the owner who said that the heating thermostat had been mistakenly turned down over the weekend. It is recommended that regular checks are made and records maintained of the temperature in the home and in resident’s bedrooms. The home was inspected by the Environmental Health Officer on 17.10.05. The report was available and stated “cleaning needed in the kitchen and a fly The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 14 screen to an opening window in the kitchen must be provided”. The owner said a further visit had been made by the EHO who was now satisfied with the standards of cleanliness in the kitchen. The fly screen remains outstanding, however, the owner said that one is currently being made. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 15 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, 28, 29 & 30 Residents are protected by robust recruitment practices. The staff group are an established team and staffing levels are sufficient to meet the current needs of residents. Staff are provided with training to ensure they have the skills needed to carry out their roles, however, they are not receiving adequate supervision. EVIDENCE: One member of staff interviewed spoke about her recruitment process and this was in line with current legislation. Records obtained included, CRB/POVA checks (Criminal Record Bureau), references, and application forms. The member of staff also confirmed that she has been given a job description but to date does not have a contract. Since the previous inspection four staff have left the home including the manager and deputy manager. This was discussed with the owner who said she felt this was expected and has since spoken to all staff individually to enable them to voice their concerns/issues with her. Residents said staff are helpful, friendly and they feel their views are listened to. They also said that they felt there were enough staff on duty, although occasionally they are short but this is usually if someone calls in sick. Staff confirmed this and said that when this happens they usually manage with existing staff. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 16 Staff have recently undertaken training in adult protection, moving and handling and health and safety. Six care staff have NVQ (National Vocational Qualifications) level 2, one also having NVQ 3. One staff is currently undertaking NVQ level 3 and 2 are waiting to commence level 2 training. However, supervision of care staff is not being carried out on a regular basis and management are required to address this issue. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 17 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): 31,33,35,36,37 & 38 Generally this home is being well managed, however, as a result of recent management changes some management tasks are being overlooked. Quality assurance monitoring should be further developed to enable people using this service to make their views known. The health, safety and welfare of residents are promoted in this home. EVIDENCE: The registered manager has recently left this home and a new manager commenced employment on 23.01.06. An application for registration is currently being completed. Since the registered manager left the provider has taken an active role in the day to day running of the home and will continue to do so until the new manager settles. A discussion was held with the provider and manager regarding the need to review care plans and this was agreed to. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 18 Quality assurance questionnaires about services provided should now be sent to all people using the service and the results of these should be published and made available to residents. A copy of this report should be sent to the Commission. It was also noted that the Commission is not being notified of significant events which affect the well-being of residents. The records of one resident stated that she had been taken to the accident and emergency department after a fall and had been subsequently admitted into hospital. The Commission had not been informed of this event. Risk assessments are documented in relation to health and safety issues that may arise from the environment of the home. Maintenance records are kept and there are a range of policies and procedures available relating to fire safety and fire risk assessments. Certificates were available showing that the stair lift and hoists have been serviced. The Old Rectory DS0000064006.V279772.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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 2 2 3 The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? 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 Residents care plans must be in sufficient detail to provide clear guidance to staff on the actions to be taken to meet their health and welfare needs. Care plans must be kept under review. Timescale of 31/10/05 not met Residents must be offered more opportunities for stimulation through leisure and recreational activities in and outside of the home to suit their needs, preferences and capacities. Although a programme of activities has been drawn up, these are not always available. All care staff should receive formal supervision at least six times per year and this form of supervision must include the requirements of Minimum Standard 36.3 Timescales of 31/05/05 and 31/11/05 not met Timescale for action 28/02/06 2. OP12 16 28/02/06 3. OP36 18 28/02/06 The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 21 4. 5. OP37 OP37 17 37 Records kept in the home must include a photograph of the resident The registered person must notify the Commission of any significant events which affect the well-being of residents. 28/02/06 28/02/06 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. 2. 3. Refer to Standard OP7 OP14 OP26 Good Practice Recommendations Staff should record more detailed information in resident’s daily contact records. Minutes of residents meetings should be available in the home for inspection. Regular checks should be made and records maintained of the temperature in the home and in resident’s bedrooms. The Old Rectory DS0000064006.V279772.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 DS0000064006.V279772.R01.S.doc Version 5.1 Page 23 - 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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