Inspection on 26/04/06 for The Old Rectory

This inspection was carried out on 26th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

The Old Rectory 23/07/09

The Old Rectory 30/04/09

The Old Rectory 03/05/07

The Old Rectory 10/11/05

The Old Rectory 27/06/05

The Old Rectory 23/11/04

The Old Rectory 26/06/04

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

CARE HOMES FOR OLDER PEOPLE The Old Rectory Church Street Tenbury Wells Worcestershire WR15 8BP Lead Inspector R McGorman Unannounced Inspection 10:30 26 April & 24th May 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Old Rectory DS0000052033.V287614.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 DS0000052033.V287614.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address Church Street Tenbury Wells Worcestershire WR15 8BP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01584 810249 01584 810249 Chantry Retirement Homes Ltd Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (28) The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate one named person under the age of 65 who has both a learning disability and physical disability. 10th November 2005 Date of last inspection Brief Description of the Service: The Old Rectory is registered to provide residential care for up to twenty-eight older people who are frail, who may have a physical disability or who may have mental health problems. Respite care can be provided when a bed is available and in addition two-day care places can be provided. The Old Rectory is an imposing listed building dating back to 1830. Previously a rectory, it is situated within 100 yards of St Mary’s Parish Church and it is also in close proximity to the centre of Tenbury Wells. The stated aim of the Home is to provide a consistently high standard of professional care, in order that service users can live as normally as possible, and where their individuality, independence and dignity are respected and upheld. The range of fees varies between £360 & £375 per week. The home was purchased by Chantry Retirement Homes Limited, in March 2004, and the directors are Mr Sefudin Hussein and Mrs Tasnim Ghiawadwala. The Registered Manager, resigned recently, therefore the deputy manager, together with Mr Hussein are taking responsibility for the day to day running of the home. An Administrator has also been appointed, together with a Regional Manager, to provide additional support for staff at the home. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine, unannounced visit, was undertaken as part of the key inspection process, the purpose of which was to monitor care provision at the home and to follow up previous requirements and recommendations. The Care Manager had resigned recently, and a new Manager was actively being sought. The Proprietor, Mr Sefudin Hussein, was present during the inspection, and time was spent discussing the current situation, and also future proposals for the Old Rectory. A Regional Manager had been appointed by the Company, and an Administrator is also employed to provide clerical support at the home. Service users and staff were consulted about their experiences of living and working at the home, and every one was very positive in their comments. Visitors and professionals who were spoken with, at the home, on the day of the inspection also expressed their satisfaction with the care provided. A tour of the premises was undertaken, and the records kept in respect of the maintenance of equipment and safe working practices, including the fire log book, were also checked during the course of the inspection. The care records of several residents were seen, and the files of some staff were also inspected. What the service does well: A warm welcome is given on arrival at The Old Rectory, and there is a calm and relaxed atmosphere, where mutual respect and consideration are constantly in evidence. The home is well maintained and cared for, and it is comfortable, safe and secure. The approach of staff is very obviously caring, which is what they consider they are good at, and this was clearly confirmed by service users, their families, and visitors to the home, with very positive comments being made, by everyone. A co-ordinator is employed specifically to organise the various past-times, and activities feature very highly at the home, with in-house and community based opportunities available. Service users confirmed the regular trips out in the minibus are very much appreciated, when the weather permits. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The care plans and daily log are being completed to a higher standard, although more detail is needed. They should be reviewed, at least every month, to enable a clear understanding of the identified needs of service users, for all involved with the provision of care. Several documents await further development, e.g. The Protection of Vulnerable Adults (POVA) procedure relating to the employment of suitable staff, the training and development assessment and profile for staff, the Fire Risk Assessment, together with general risk assessments, in respect of all safe working practices, and also an emergency evacuation plan should be introduced. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 7 Fully implement a quality assurance programme, to identify the ongoing improvements, and to enable the effectiveness of the service in meeting the aims and objectives, to be measured. The appointment of a care manager should be made at the earliest opportunity. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, 5 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The information available for a prospective service user, enables an informed decision to be made about their future care needs. The admission procedure provides an appropriate introduction to the home. The assessment undertaken prior to admission, should be more detailed to ensure that the home is able to meet the identified needs of service users. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 10 EVIDENCE: The Statement of Purpose has been amended to include the information required by this standard, and the Service Users’ Guide, which has been produced in the form of a booklet, provides some additional information about the home for prospective service users. Copies of these documents are to be submitted to the Commission. A satisfactory admission procedure is in place, although this needs to include a more detailed process for dealing with emergency admissions to the home. The Care Manager or Deputy undertakes a pre admission assessment for all prospective service users, either at home or in hospital, following the initial referral. A visit to The Old Rectory is encouraged, and prospective service users are invited to spend time with the resident group and to have a meal. Arrangements may also be made for a short stay, if this is preferable, prior to making a decision about future care needs. The need for a more detailed assessment to be completed by staff, for service users who are self-funding, or a full Community Care Assessment to be obtained from the placing authority, prior to admission, was discussed with the Proprietor. Intermediate care is not provided at The Old Rectory. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The content of the care plans needs to be more detailed, to provide evidence that the personal and healthcare needs of residents are being fully met. The policy and procedures covering the administration of medication ensure the protection of service users. The privacy and dignity of service users was respected, and the atmosphere throughout the home was one of mutual esteem and regard. Staff demonstrated a good understanding of the needs of service users, and offer care in a way that encourages and promotes their independence. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 12 EVIDENCE: The care plans of four service users were examined, and evidence seen of improvements in the process, although monthly reviews had not been completed recently, following the resignation of the Registered Manager, who had been developing the procedures. The content of the care plans should be more detailed, with greater involvement of the service user and their family or representative. The plan should also be signed by the service user to indicate agreement and acceptance of the contents. The daily log is being completed to a satisfactory standard, and specific information transferred to the care plan, for example, details of visits from health care professionals. The health and personal care needs of residents are monitored and the home is well supported by the Primary Health Care Team. Specialist treatment can be accessed, and the advice of the continence nurse is sought when necessary. Risk assessments are completed, in respect of mobility, moving and handling, and tissue viability, and the weight of service users is monitored. The need for all documentation to be reviewed regularly, and up to date records maintained was discussed with the Proprietor. The Medication Administration Records were seen during the inspection, and had been completed to a satisfactory standard. Appropriate action has been taken, following a recent error, to prevent a recurrence, and further training provided for staff. Evidence to indicate that service users are treated with dignity and respect was observed in the interactions of staff with service users, and was also confirmed in discussion with them. Visitors were equally complimentary about the care provided to their relatives and friends at the home, and about the kindness of staff, and comments from all concerned included the following: • I’m a lucky fellow • I wouldn’t change anything • I would tell them if things were not right • The minibus trips are very enjoyable • There’s always plenty to do • I’m comfortable and content • Everyone is very caring – some have more time than others • Some staff are good and some are very good • I do as I please – go to bed when I want and get up when I want • There is always an immediate response to my ringing the bell • I feel safe and secure The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. The social, emotional and spiritual needs of service users are identified, and various recreational opportunities provided to ensure their interests are fulfilled. The wishes and preferences of service users are respected, and they are encouraged to make choices about all the activities of daily living, and to have as much control over their lives as they are able. The Old Rectory is part of the local community, and service users have complete freedom in regard to their contacts, both within and outside the home, which enables a good quality of life to be maintained. Service users are offered a choice of nutritious, wholesome and well-balanced meals. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 14 EVIDENCE: Service users confirmed they are able to choose how they spend their time. They have complete freedom in regard to their contacts, both within and outside the home. Their wishes and preferences are respected, and they are encouraged to make choices about all the activities of daily living. Organised activities are regularly available, although some people prefer to stay quietly in their own room. The home employs an activities organiser, who works individually with service users, arranges some group activities, and also encourages involvement with the local community. Examples include: • • • • • • • • Knitter/natter sessions Bingo Jigsaws Fish and chip suppers Shopping Board games Painting Celebrating seasonal events The home has a minibus to take the more adventurous a little further from home, and they visit various places of interest, stop somewhere for afternoon tea, or an ice cream, or just go for a ride. The spiritual needs of service users are considered. A monthly service is held at the Home, and residents are able to attend church, if they wish. The home is very much part of the local community, and its proximity to the town centre is of benefit in this respect. The involvement of family and friends is actively encouraged, and visitors are always welcome. The home describes itself as having an open door policy. Fund raising activities are organised, and have included a coffee morning, a garden fete and a strawberry tea. Pupils from the local school are doing a community project that involves the home, and they are doing some ‘Art Classes’ with service users. The daily menu is posted on the notice board, and the four-week menu plan indicated that a good variety of food is available. Special dietary requirements can be provided and currently include diabetic and light/gastric diets. Only favourable comments were heard regarding the standard of the food at the home, and a service user whose diabetes is diet controlled stated, ‘the food is excellent, they know what I like and always ask my preference.’ A record of the food provided to each service user is maintained, therefore it is possible to ensure that a satisfactory diet is taken by everyone. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service. A record of all complaints, comments and compliments is maintained, to provide evidence that all concerns are responded to appropriately. The absence of policies and procedures relating to staff who may be unsuitable to work with vulnerable people places service users at possible risk of harm or abuse. EVIDENCE: A satisfactory complaints procedure has been produced and is accessible to service users and their families. There have been no recent complaints made to the home or to the Commission. A record of complaints, comments and compliments is now maintained, although very few remarks had been noted. A balanced approach is necessary, and should include the many positive comments that are often made, together with any areas of concern that may also be mentioned. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 16 The policy and procedure on adult protection at The Old Rectory, had been amended, as previously requested, to reflect the change of management of the home, but a copy has not yet been submitted to the Commission. Training has been provided for staff, to increase their awareness of the many aspects of abuse, and staff confirmed their understanding of these matters during discussions with them, at the time of the visit. A policy and procedure in relation to staff who may be unsuitable to work with vulnerable people, remains outstanding therefore this should be introduced without further delay, and a copy of this procedure also submitted to the Commission. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 & 26 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. The premises are suitable for their purpose. The building is well maintained, the standard of cleanliness is satisfactory, and the décor and furnishings are in good condition, providing a very comfortable and homely environment that ensures, as far as possible, the safety of service users. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 18 EVIDENCE: The Old Rectory is located in a quiet area of Tenbury Wells, with easy access to the town centre. The house was converted into a residential home in 1985, and has been developed and upgraded to provide comfortable and wellmaintained accommodation. The grounds, although not extensive, are accessible to residents. There are two pleasant lounges situated on the ground floor, and a large dining room. The communal areas of the home are furnished and decorated to a high standard, and a maintenance programme is in place. Service users bedrooms are well ventilated and centrally heated, with each radiator having an individual thermostat. The Proprietor confirmed that the guarding of the pipe work and radiators throughout the house has now been completed. Emergency lighting is provided throughout the Home and a generator was available to maintain power supplies in the event of an electricity failure. The provision of a conservatory, which would further enhance the communal space available to service users has previously been considered, and may be a project for the future. Proposals for upgrading the kitchen and the development of a hairdressing facility are included in the business plan for the home, and will be considered as part of the ongoing improvements at The Old Rectory. The Proprietor confirmed there are no outstanding requirements following a visit to the home by the Environmental Health Officer in November 2005. The Home is clean and odour free, and infection control procedures are followed. Protective clothing is provided, and staff confirmed that training in health and safety matters is provided. The home received a visit earlier this week from the Fire Safety Officer, who requested a grill to be fitted in the stock room. The Fire Safety Precautions within the home were otherwise considered to be satisfactory. The Fire Log book was checked, and appropriate records are being maintained. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. The staff team is now more stable, and staffing levels are being maintained at an adequate level to meet the needs of service users. Many staff are experienced and competent in their work, and ongoing training is now being provided, which, together with the continuing commitment to NVQ training should ensure the appropriate delivery of care for service users. Recruitment procedures are being implemented to a more satisfactory standard, which should ensure the protection of service users. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 20 EVIDENCE: The rotas confirmed that a minimum of three care staff are on duty throughout the waking day, and at night there are two waking staff. Catering, domestic and maintenance staff are also employed. The staff team is now more settled, with only two staff who retired in the last six months. The need to continue to monitor staffing levels closely, to reflect the identified needs of service users, was discussed with the Proprietor. Several staff were interviewed, and confirmed that they enjoyed their work. Their comments were very positive about their employment at the home, and the training opportunities that were now provided. Over 50 of the care staff have the NVQ Level 2 in Care, and four staff are currently taking the award, with another two carers having just commenced the course. Three staff have completed Level 3. There is a training programme in place, which has recently included the following: • Induction • Basic Food Hygiene • Moving and Handling • Fire Awareness • Basic First Aid • Medication Administration • Care Planning The need for a review of the training needs of each member of staff, and the development of an individual training and development assessment and profile was again identified. Recruitment procedures are satisfactory, and the staff files indicate that the relevant documentation is in place. The application form has been amended to include appropriate information. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service. The absence of a registered manager will inevitably have an adverse affect on the smooth running of the home. There is no quality assurance system in place to ensure that the home is run in the best interests of the service users. The interests of service users and staff are not safeguarded by the absence of appropriate risk assessment in respect of all safe working practices. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 22 EVIDENCE: The care manager has resigned recently, and the company are actively seeking a replacement. The Deputy, Mrs Ann Rogers is again taking responsibility for the day to day running of the home, with assistance from the Proprietor. A Regional Manager has been appointed, and the intention is for additional support to be provided to The Old Rectory, in the absence of a registered manager. In addition an Administrator has also joined the staff team, which will relieve care staff of some administrative tasks. A quality monitoring system has not been fully implemented at The Old Rectory, although questionnaires have been circulated, which have yet to be audited. The previous manager was undertaking a project at College relating to the development of a quality assurance programme, but resigned prior to its completion. The management of the home confirmed that staff have no dealings with the financial affairs of service users. Arrangements are in place for the family or a representative to take responsibility, where a service user lacks capacity or does not wish to be involved. Verbal confirmation was received from the Proprietor in regard to the financial viability of the business, and an annual business and financial plan is to be submitted to the Commission. Appropriate insurance cover is provided, in respect of all aspects of the business. The records seen during the inspection are being maintained to a satisfactory standard. A review of the policies and procedures has been undertaken recently, and copies are available for information in the staff room. The Accident Books have been completed to a satisfactory standard, and Regulation 37 Notifications made to the Commission, when appropriate. The Commission is now receiving regular reports on the conduct of the care home, from the Responsible Individual, in respect of monthly visits to the home under Regulation 26. Contracts are in place for the regular servicing and maintenance of equipment. A health and safety audit is being developed, although risk assessments in respect of safe working practices, and the recording of significant findings, remain outstanding. A Fire Risk Assessment for the home is being produced, and this was discussed with the Fire Safety Officer during the recent visit. An emergency evacuation plan is also being developed. The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 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 2 X 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 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 OP3 Regulation 14 Requirement A detailed, written assessment must be completed before the admission of any service user and in accordance with the requirements of Regulation 14 and Standard 3 Timescale for action 30/09/06 2 OP7 15 A detailed plan of care must be 30/09/06 maintained for each service user, and reviewed by staff at least once a month, with the involvement of the service user or their representative A manager must be appointed at the home and an application for registration submitted to the Commission A quality assurance system must be introduced in accordance with the requirements of Regulation 24 & Standard 33 (Timescale of 31/12/05 not met) The health and safety of service users must be promoted by undertaking risk assessment in respect of all parts of the home DS0000052033.V287614.R01.S.doc 3 OP31 8 30/09/06 4 OP33 24 30/09/06 5 OP38 13 30/09/06 The Old Rectory Version 5.1 Page 25 to which they have access, any activities in which they participate and for all safe working practices (Timescale of 31/12/05 not met) 6 OP38 23 The registered person must take 30/09/06 adequate precautions against the risk of fire. A fire risk assessment must be developed (Timescale of 31/12/05 not met) 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 OP4 Good Practice Recommendations A copy of all amended documentation should be submitted to the Commission on completion, including the procedure for emergency admission A record should be kept of all comments, including compliments, about service provision at the home A procedure should be developed in relation to staff who may be unsuitable to work with vulnerable adults, and who may need to be considered for inclusion on the POVA register An emergency contingency plan should be developed for the home in the event of an evacuation being necessary Consideration should continue to be given to the proposals for further improving facilities at the home i.e. conservatory, hair dressing room, upgrading of the kitchen An individual training and development assessment and profile should be provided for all staff A copy of the business and financial plan for the establishment should be submitted to the Commission 2 3 OP16 OP18 4 5 OP19 OP19 6 7 OP30 OP34 The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Rectory DS0000052033.V287614.R01.S.doc Version 5.1 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!