Inspection on 24/06/09 for The Old Rectory

This inspection was carried out on 24th June 2009.

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

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

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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Old Rectory Main Road Stickney Lincolnshire PE22 8AY Lead Inspector Vanessa Gent Key Unannounced Inspection 24th June 2009 10:30 DS0000073196.V376536.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address Main Road Stickney Lincolnshire PE22 8AY 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) 01205480885 01205481259 Prime Life Ltd Cheryl Shave Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability (44) of places The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical Disability - Code PD The maximum number of service users who can be accommodated is 44 2. Date of last inspection Brief Description of the Service: The Old Rectory is a privately-run, care home providing personal care for up to forty-four older people of either sex over 65 years of age, some of whom may have a physical disability. It is a large, 18th century country house with three additional purpose-built wings, situated on the high street in the village of Stickney, on a main bus route eight miles from the town of Boston. The village has a church, shops, hairdresser’s, post office, pub, doctor’s surgery, primary school and nearby, the tourist attraction of Stickney Farm Park. It was purchased by its present owners, Prime Life Limited, in December 2008. The accommodation consists of forty-three single rooms, fourteen of which are en-suite with a toilet and washbasin. Communally there are three lounges, one for smokers, one dining room, three bathrooms, and one shower-room, all with a toilet, and five toilets. The upper floor can be reached by a passenger lift, two stair lifts and three staircases. The grounds extend to over one acre, with a garden at the front and a further large garden at the rear, part of which is in the process of being landscaped to provide a secure, tranquil outdoor area. There two car parks, one for visitors and one for staff. The weekly fees range from £402 to £450. Additional charges are made for services such as hairdressing, chiropody, toiletries and personal newspapers and magazines. Information about these costs as well as the The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 5 day-to-day operation of the home can be found in the statement of purpose and service user guide. These documents, the certificate confirming registration conditions and a copy of the previous inspection report are available to anyone interested in coming to live at the home and those already living there. An intermediate care service is not provided at the home. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Throughout this report the terms “we” and “us” refer to the Care Quality Commission which, since 1st April 2009, became the new independent regulator of all health and adult social care in England. The people who live at the home told us that they would like to be referred to as residents. An unannounced visit by two inspectors was made to the home as part of a key inspection. It started at 10.30 and lasted seven hours and twenty minutes. The manager had completed a questionnaire giving information about the service and this was used to contribute to the inspection process. This and other information we hold about the service was used to plan the visit and produce this report. The main method of gathering information during this visit involved selecting some of the residents, and looking at the way care was given to them by checking their personal records, talking with them, the care staff and any visitors and observing care practices. The visit to the home also focused on whether key standards and requirements from the previous random inspection had been met and how the people feel about the service provided. We looked particularly at the care given to five people to ensure their health, safety and welfare is checked and that they are given dignity, autonomy and choice. We spoke with these residents, other people either in their own rooms or in various communal areas of the home, and several visitors and most of the staff on duty. People spoke about their experience of living at the home. We looked at records kept for the running of the home and staff records. Any comments we received are mentioned in the main body of this report. We looked at parts of the home; there was major refurbishment work being undertaken to improve the environment for the people who live there. The manager was on the premises during this inspection and we were able to talk with her at the beginning and end of our visit. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 7 What the service does well: The home is clean, tidy and provides a homely place for residents to live in. Relatives and visitors were actively encouraged to visit, felt welcomed and joined in the activities if they so wished. Staff had received sufficient training to provide a caring service to the residents. What has improved since the last inspection? What they could do better: Care plans must contain a record of the following; follow up to any incidents or accidents, the monitoring of health needs, a description of what action was taken or how the staff manage a situation. When the care plans are reviewed monthly, they must have evidence that the resident or their legal representative has been involved. Medication administration records must be kept accurately to reflect exactly what has occurred. Staff must follow medication guideline to ensure that practices are always safe and hygienic. Staff must always treat the residents with dignity and respect. The manager and staff must ensure that the residents are supported in pursuing any daily activities to ensure their wishes and needs are met. All staff should receive training to know how to assess people’s capacity to make decisions for themselves. The quality and variety of the food provided must suit the wishes, needs and preferences of the people who live at the home. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 8 The manager must act upon what people tell her when they are not happy about something, and advise them of the outcome. A record of these events must also be maintained. This is to ensure that the residents know they have been listened to and that issues are acted upon in a timely manner. The staff must ensure that they complete tasks in a timely manner to ensure resident’s needs are met. The resident’s opinions, views, wishes and preferences must be taken into consideration to ensure that the service is tailored to individual needs. Any faults identified about the building must be reported and acted upon in a timely manner to ensure that services to residents are maintained at an acceptable level. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 9 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 DS0000073196.V376536.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive enough information to help them decide if the home is going to meet their needs and wishes. The manager obtains enough information about a person to know if they can provide a suitable service for them. EVIDENCE: The statement of purpose and service user guide we saw contained material put together by Prime Life for use in their homes generally as well as individual details of this service. Some people told us they were unaware of the brochure pack but most had lived at the home before the new owners took over, said they were comfortable and that the manager and staff looked after them well. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 11 The statement of purpose stated that specific information about various aspects of the service could be obtained by consulting with the manager. The service user guide is a glossy brochure, entitled “An Introduction to Bespoke Services to Elderly Client”. It is written in large print with associated pictures and brief descriptions. People told us that they were visited in their previous location by the manager or a member of staff to ask them questions and tell them about what living at the home would be like. The manager confirmed that she or a senior staff member visited people before offering them a place at the home. We saw in people’s care plans that this assessment formed the basis of the care plans once the person came to live at the home. We looked at the records of one person who had recently come to live at the home and talked with them about their experience. The person’s records showed that an assessment of their needs had been carried out, including a getting to know you form covering a range of information such as any significant life events for the staff to be aware of such as their religion, hobbies and previous life experiences. The person we spoke with said they had settled in well and found their room comfortable. An intermediate care service is not offered. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans do not contain sufficient information to ensure that all of the resident’s needs can be met Medication guidelines are no sufficiently adhered to, to ensure that residents medical needs can be met. EVIDENCE: The manager told us that they are introducing a new care planning system and have begun gathering information towards a more person-centred style. A report from the company’s recent unannounced visit to the home stated that all people now have a new care plan in place. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 13 The care plans we looked had been updated; we saw the resident’s needs and choices were recorded and risk assessments were carried out to help them live as they wished. However, some care plans did not show how staff have updated them following accidents or incidents, or how the manager or senior staff monitored how many accidents people had over a period of time. In one person’s care plans, there was no indication whether or not staff had put in place any means of reducing the risk of falls that had occurred. For one resident, incident records were kept of the number of falls but it was noted that the recording of one fall was not fully completed with details as to whether their GP had been called and the incident form was not signed. The corresponding daily records did not show whether the person was given any opportunity of seeing GP. A staff member said that some staff let the side down because “they do not do good enough recording in the residents’ records” and it meant that the other staff may not always know how to care appropriately for the residents or what has taken place. The provider informed us, “we constantly review the service that we deliver, we involve our clients and where appropriate their supporters and the external professionals”. The staff review the care plans on a monthly basis and there are some recordings where the resident or their representative have been involved. Several of the residents told us they were aware of their care plans but those not involved in them either said it was by choice or because they had not been asked. Charts were being used to detail the amount of fluid being taken by people who were poorly. However, some of these were not kept up-to-date. A staff member said that the staff sometimes do not complete the fluid records as carefully as they should but that they, the care staff, try to make sure people get enough to drink. Some residents told us they believed that staff would always call a doctor or healthcare professional if they were ill or had an accident. The safeguarding team made a recommendation that the manager and staff should liaise better with the healthcare professionals such as district nurses, local surgery team and other professionals. Staff said that this has improved. However, we found that care plan records indicated instances where people had fallen and sustained a head injury but professional help had not been called. The manager said she would look into this matter and speak with staff to ensure accurate recording was always done and that professionals were called for guidance and advice in future. In two of the medication records where medicines were not given, the reason was omitted from the record. A concern had been noted before our visit about this and the provider had responded that they are providing refresher training. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 14 We noticed that some medicines were not given till late in the morning but signed for as given at breakfast. A complaint was made by a relative of a resident who observed that staff had made errors in the dosage of medicine given. Staff had not noticed this until it was pointed out to them by the relative. The provider had told us that after a visit to the home by a representative of the company in June 2009 also identified that medication errors had been made. We saw in staff records and in talking with them and the manager, that training for safely giving out the medicines was currently being completed by seven of the staff although one staff told us, and her records confirmed, that their last training for this had been two years previously. The manager told us that staff had been “reminded about the importance of keeping accurate medication records” and that she had also been supervising some staff to monitor safe medicine administration. The supplying pharmacist visits the home regularly, audits the service and trains the staff in safe medication administration. People told us that the manager and staff treated them with dignity and respect. However, we observed a person who had difficulty managing their food and drink was not supported throughout the mealtime. The person could not manage to eat much of the meal and spilt the drink into their lap. One of the inspectors had to make staff aware of the situation, at which point they attended promptly to change the person’s clothes. A person who had no shoes on said that their shoes had been taken to be cleaned earlier in the week and had not been returned yet. The staff said they had not been returned, as the person had pressure sores. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s choices are limited by a lack of information in their care plans and a lack of understanding by the staff of their wishes and needs. EVIDENCE: Although we were told there is an activity programme, staff showed they were not aware of it and did not provide what we saw on the programme for the day we visited. No activities were undertaken during our visit. Residents and their visitors agreed there was not enough variety or quantity of activities, nor had they been consulted on what activities they wanted. One resident said that the number of staff on duty was cut when the new owners took over. It meant, they said, that staff “haven’t got time to spend with you.” Others said, “There’s nothing really to do all day. We watch TV a lot.” A visitor told us, “There’s not much in the way of activities. They used to have an activity organiser but not now. Staff regularly tell us ‘we’re shortstaffed’ as a reason for not doing activities or other things we ask.” The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 16 The provider told us, “We provide choices and options, varying from clients being involved in simple issues revolving around the daily delivery of care, assisting with domestic activities, through to more adventurous options, to assisting clients to access the community and to take advantage of the social and leisure activities on offer.” People we spoke with said they can choose what they do during the day and where they sit, either in their rooms or in communal areas. The manager and a senior staff member had received training on how to assess people’s capacity to make significant decisions. The care plans we saw did not reflect how this was assessed or determined. The manager said there were plans to train all the staff to help them assist people to make decisions for themselves. We were told by the manager, “We attach great importance to our catering provision, as a source of nutrition or benefit and good health, but also as a social opportunity, we ensure that our meals are nutritious and tasty, but served in a flexible, relaxed and unhurried fashion”. However, we received varying comments from residents about the meals and particular reference was made to the fish and meat dishes and the oil and gravy contents. Drinks were available and given to residents during our visit but at the lunch meal no drinks were offered or given to the residents until the meal was finished. The hot drinks given out after the meal were supplied from a central commercial size container. People told us they would like to have had jugs of squash or water on their meal tables during their meal to pour their own drinks and that they would like a tea or coffee pot, milk jug and sugar bowl on the table for them to serve themselves after the meal. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedures are not sufficiently robust to ensure that residents wishes are carried out or that their complaints are dealt with. EVIDENCE: The complaint records showed one complaint was received on 17th June 2009 which was investigated by manager but she had not recorded clearly whether the matter had been satisfactorily resolved. Several people said they would feel comfortable to raise any problems and thought the manager would do something about them. However, two people said, “You can make complaints but you won’t be listened to.” Another person said, “I’m listened to but often nothing’s done about it.” Visitors told us, “Most weeks there’s something to complain about.” “I complain all the time when I’m not happy about things but the acting manager doesn’t always get back to me. Things change for a few days then they’re back to normal and I have to start with the same complaint again.” A relative said they had received a letter from Prime Life when they first took over but could not recall being given a copy of the complaints procedure. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 18 The staff told us that they understand how to protect the residents, and that they have received training in how to prevent abuse from happening and how to make management aware if they were not happy with a colleague’s behaviour or practice. The staff training matrix showed that staff were up-todate with abuse awareness and protecting vulnerable adults training. One complaint relating to care and staffing has been referred to Lincolnshire County Council Safe Guarding Adults team and has been investigated by them. As a result of the investigation further training has been provided to the staff by the company. Staff support and supervision has also been increased. The manager said that they now always report any incidents to us. We saw on the home’s service file that we had been notified when people had fallen or been taken to hospital and when a theft had occurred. People told us they mostly feel safely cared for by the staff, although they added that often being short of staff means that the staff do not always see what is going on and accidents happen when they are not around. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is clean and homely and is being developed to ensure that residents’ needs continue to be met. EVIDENCE: A major refurbishment programme of the home was underway in the home. Redecoration was in progress and new flooring has been laid in corridors and on staircases. Staff said there had been a problem with the domestic hot water supply in one part of the building. Residents said also that this had occurred. Some work had been completed to try to remedy this, but the problem was not yet fully solved. Boilers had been checked and timers reset, and this was being monitored. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 20 One inspector saw two resident’s rooms and these were clean, tidy and personalised with the residents own belongings. The rooms also contained equipment which was provided to help meet individual needs. There were no unpleasant odours detected anywhere in the home. The lounges next to the dining room were clean and tidy and had a large screen television and music system. Safety chains were attached to windows on the firs floor, to protect residents from falling out. One hoist shown to one inspector, in a bathroom, was not working. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the staff that are on duty is not sufficiently robust to ensure that resident’s needs are met or that they are protected. The robust staff recruitment procedure ensures residents are protected. EVIDENCE: The staff duty rota we saw showed that altogether there was one senior and four to five care staff on duty for the morning and evening shifts and at nights, three staff. It was noted however, that where staff were on sick or annual leave, they were not always replaced, so the staffing numbers were down on these shifts. One staff member said that staffing levels were sufficient to meet people needs. Two other staff did not feel staffing levels were sufficient and said they had to fulfil other duties if staff were off sick, as they were not replaced, for example in the kitchen and laundry. Staff said “last night there were only two staff on duty”. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 22 A resident said, “There are not always enough staff on duty at night. Sometimes there’s three but last night there were only two and I had to call for assistance due to my friend (another resident) being poorly”. A relative said they felt there were usually enough staff on duty but added, “It’s whether they’re efficient enough”. They said that sometimes call bells rang for a long time. They would like staff to “look in on [the resident] more often and not leave [them] so long.” They said that staff and the manager chat to them although they felt they were not always really listened to. At 3pm one of the inspectors heard a resident ask a member of staff if she was going to come and provide help with washing and teeth cleaning as this had not take place since they had woken that morning. The resident told the inspector that it was not his choice to wait this long. Staff and the management confirmed that of the twenty-five residents currently living in the home, “quite a lot of people” had high dependency needs. A staff member commented that if a resident wanted a bath every day they would not be able to have one because of the staffing levels. Staff told us, “One or two [staff] could be more enthusiastic but generally we’ve got a good team”. In the last report from the head office person’s visit to the home, there were concerns raised in relation to a particular staff’s attitude and time keeping. It was also noted in the minutes of the staff meeting that took place on 8th May that staff attitude was raised as an issue. We were told by recently employed staff that they did not start work until all the checks required by law were completed. They told us that they had a solid introduction on how to care for the residents safely and appropriately. The manager told us that the company had its own induction training package called ‘Early Days Mentoring’ but that she also used the ‘Common Induction Standards’ training. Staff told us that they were more supported since the new management has become established and some staff had left and been replaced. The staff training matrix chart was displayed on the wall where staff and others can check it. It showed that basic training sessions, including protecting vulnerable people, fire safety, first aid, safe administration of medications, moving and handling, dementia awareness, physical intervention and health and safety had been provided and undertaken by all the staff since the new company took over. The manager told us that extra courses currently being planned included The Mental Capacity Act 2005 and Deprivation of Liberty Act 2008. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management systems of the home are not sufficiently robust to ensure that residents’ needs are always met. EVIDENCE: The manager was registered with us on 6th April 2009. She worked full time and did not have any caring shifts to do. She had an administrator who worked from 09:00 till 13:00 five days a week to help her keep the paperwork and finances correct and up-to-date. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 24 The manager told us she had an ‘open door’ policy for people to approach her. Residents confirmed this but some people added that they found she was not acting upon what they told her that they were not happy about. Staff said that they felt the manager and company representatives were supportive and approachable. One said the manager had helped them during a difficult period which had enabled them to continue working in a flexible way. The company sends someone, unannounced, from head office every month to check the property and speak with residents, visitors, staff and the manager, and reports in writing on their findings. The manager told us that they plan that residents’ and relatives’ surveys would be distributed as soon as the refurbishment programme is complete but it had not been done yet. She told us that residents and relatives had their own meetings including coffee mornings every week. Once a month, she said, these are formal residents’ meetings to which relatives and visitors are also invited to attend. Staff also had regular meetings although staff said these were not as regular as they need to feel fully supported in their practice. Some staff told us they had had a one-to-one meeting with the manager although the manager told us these formal, documented meetings with staff have not been fully implemented enough to support them in all aspects of their work. She said, and staff confirmed, that she regularly chats to them but that mostly it is on an informal basis and nothing is written down. We were told that there was a maintenance man available and we saw the maintenance records kept. Faults that had been reported, such as a section of the home without hot water and a faulty bath hoist-seat, and these were still not repaired at the time of our visit. When asked if they felt the manager, staff and company could do better, one resident told us, “I don’t think there’s anything. I’m quite happy here.” A visiting relative said that it was generally better than before the new owners took over. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 3 The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(C) Requirement The care plans and recording must be completed in sufficient detail to ensure that staff know what has taken place and what care to provide for the residents at all times. There must be robust recording in people’s care plans following accidents or incidents and access to healthcare professionals must be identified as necessary as in Schedule 3 (3)(j). Medication practices must be safe and medication administration records accurately kept at all times to ensure health needs of residents are met Residents must be treated with dignity at all times. Support must be provided to enable residents to undertake activities and personal interests, to ensure their wishes and needs are met. When people raise a complaint, the record must show how they are responded to, and the outcome of action taken to ensure a satisfactory conclusion DS0000073196.V376536.R01.S.doc Timescale for action 30/09/09 2. OP8 13(1)(b) 30/09/09 3. OP9 13(2) 30/09/09 3. 4. OP10 OP12 12(4)(a) 16(2)(n) 30/09/09 30/09/09 5. OP16 22(4) 30/09/09 The Old Rectory Version 5.2 Page 27 6. OP19 23(2)(b) 7. OP27 8. OP33 The premises, fixtures and fittings must be maintained in a timely and suitable manner for the residents’ comfort and safety. 18(1)(a) There must be sufficient staff on duty, and appropriately deployed, who are competent and experienced to ensure that resident are met. 24(1)(a,b) There must be a comprehensive method of gaining all aspects of the views, opinions and wishes of residents, relatives or staff to provide a service that meets people’s requirements and wishes. 30/09/09 30/09/09 30/09/09 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. Refer to Standard OP14 OP36 Good Practice Recommendations Staff should receive training in how to assess people’s capacity to make decisions for themselves in their lives. It is recommended that staff receive supervision on a formal basis up to six times a year. The Old Rectory DS0000073196.V376536.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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