Inspection on 26/09/05 for The Old Rectory

This inspection was carried out on 26th September 2005.

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

The inspector 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 24/01/06

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 26th September 2005 10:15 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.V252659.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 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 Mrs Wendy Drakes Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 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 22/02/05 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.V252659.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours and was carried out by one inspector as the first of two statutory inspections for 2005/6. The Commission had not received the pre-inspection questionnaire prior to the inspection, however, seven relative/visitor comment cards were returned and information was gathered from these. 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. It also included a general discussion with other residents whilst they were having lunch. Three bedrooms were viewed and a selection of care records inspected. The registered owner is available daily for advice and the day to day responsibilities are carried out by the registered manager. What the service does well: What has improved since the last inspection? What they could do better: All residents must be given contracts/terms and conditions from the new owners. Management should carry out risk assessments with regards to staff deployment to ensure residents needs are met. Up to date training must be provided to all staff regarding health and safety and moving and handling. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 6 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.V252659.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Residents are admitted into the home only after a full needs assessment has been carried out and written confirmation has been sent assuring them that their needs will be met. EVIDENCE: Care records of two residents recently admitted showed that a pre-admission assessment had been carried out forming the basis of their care plans. One resident said that they chose the home with the help of their family and whilst other residents spoken to could not remember the arrangements for coming into the home their records showed that assessments had been carried out. Both staff spoken to knew about the care needs of the residents and were aware of the home’s pre-admission assessment procedure. They also confirmed that the manager always discusses the needs of prospective residents prior to their admission. The owner said that the Service User Guide and Statement of Purpose is currently being updated and will be given to all residents and their relatives/representatives on completion. One comment card received read “we The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 9 have never had a contract”, and this was discussed with the owner who stated that new contracts are being drawn up. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 10 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 and 10 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. Plans are very basic and not all have been reviewed regularly. One relative comment card read “never seen a care plan”, when this was discussed with the owner and manager they explained that some residents choose not to involve their relatives in the care planning process. However, records must show that relatives/representatives are involved for residents who cannot make this choice. One resident spoken to said that she felt the home meets her current needs but was not aware of a care plan. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 11 Records did include appointments made to visit the dentist, optician and chiropodists. Residents spoken to said that they felt their privacy and dignity is respected, ‘staff knock on doors’ and ‘speak with great respect’. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 12 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 & 15 Relatives and friends of residents are made welcome in this home. Meals are well managed and reflect resident’s likes and dislikes. Residents living in this home would benefit from more activities than those currently offered. EVIDENCE: Residents spoken to said that they were generally happy with the food provided, commenting that the food “is good” “very nice” and “always fresh” although one resident said they would like to have more variety. Care plans do not show residents likes and dislikes in detail but all said the cook knows their preferences. Tables were laid with clean tablecloths and the lunchtime meal was roast turkey, stuffing, mashed potatoes and vegetables, this was nicely presented, and there was a choice of rice pudding or yogurt for desert. One relative was spoken to and confirmed that she can visit at anytime. Residents also said that they are able to see their visitors when they want and in privacy and can choose not to see a visitor. Comment cards read “the staff are always welcoming” and “the home has a very nice feel to it”. The home provides a small range of activities which are carried out once a week. These include movement to music and quizzes. In addition to this two The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 13 residents go to a club every Monday and two residents go to church weekly and an organist comes in to have a sing-a-long with residents once a month. Residents spoken to said they would like activities to be available more frequently and one relative/visitor comment card read “planned activities are poor”. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 14 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 The home takes the issue of addressing complaints very seriously and residents are confident that their concerns will be listened to and acted upon. Although the complaints procedure will be contained within the Statement of Purpose and Service User Guide this is not yet available. EVIDENCE: One complaint has been received by the CSCI since the last inspection. Staff spoken to knew what action to take should they receive a complaint but were unclear on the reporting procedures should they need to report an abuse allegation. One member of staff said that she had looked at the types of abuse during National Vocational Qualification (NVQ) training but neither staff had any training regarding the reporting process. Residents said that they had not seen a written complaints procedure but they felt that they could raise any concerns with the manager and were confident that action would be taken to address these. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 15 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 Residents living in this home live in a clean, comfortable and homely environment. However, the health and safety of residents and staff may be at risk as staff have not undertaken updates in health and safety and moving and handling training. EVIDENCE: The home is clean and well decorated. All furnishings are of a domestic nature and residents said they like the home and are happy with their bedrooms and these are kept clean. Since the change of ownership one carpet has been replaced and another cleaned. Staff said they felt they worked in a safe environment and said that they are currently undertaking a de-contamination course. However, the dishwasher is currently out of action and staff are hand washing dishes and only have the facility of one sink. Staff spoken to also said that they had not completed updates in health and safety or moving and handling training. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The staff group are an established team and know the needs of residents and the action needed to meet their needs. However, the deployment and numbers of staff available in the mornings should be reviewed to ensure sufficient staff are available to meet these needs. EVIDENCE: There is a low staff turnover in this home and many staff have been here for a number of years. Residents spoken to said that staff in the home are kind and approachable and that they felt staff listened to them. One resident said “the staff are splendid, you couldn’t find better”. Records showed that there are always three care staff on duty in the mornings and three in the afternoons. There are two wakeful staff at night. Management hours are supernumerary. Staff said they felt there is sufficient staff on duty to attend to the care needs of residents, however, they are having to carry out laundry duties and at present are washing dishes. Two relative/visitor comment cards indicated that in their opinion there was not always sufficient numbers of staff on duty. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 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): The above standards were not inspected on this occasion EVIDENCE: The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 19 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 OP1 Regulation 5 Requirement A Statement of Purpose and Service User Guide must be written and given to each resident. All residents must be given individual contracts/terms and conditions of residency. 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. 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. A written complaints procedure must be made available to all residents relatives and visitors. All staff must receive training regarding adult protection and this should include the reporting process. All staff must receive up to date health and safety and moving and handling training. Equipment provided in the home DS0000064006.V252659.R01.S.doc Timescale for action 31/10/05 2 OP7 15 31/10/05 3 OP12 16 30/11/05 4 5 OP16 OP18 22 13 31/10/05 31/12/05 6 7 OP19 OP19 13 23 31/12/05 31/10/05 Page 20 The Old Rectory Version 5.0 8 OP36 18 must be in good working order, therefore, the dishwasher must be repaired or replaced. 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 (previous timescale of 31/05/05 not met) 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP27 Good Practice Recommendations It is recommended that the owner signs the ‘fire signing in/out book’ on every visit. Staff deployment should be reviewed regularly to ensure sufficient staff are available to meet residents needs. The Old Rectory DS0000064006.V252659.R01.S.doc Version 5.0 Page 21 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.V252659.R01.S.doc Version 5.0 Page 22 - 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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