Inspection on 27/06/05 for The Old Rectory

This inspection was carried out on 27th June 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 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 26/04/06

The Old Rectory 10/11/05

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 Rachel McGorman Unannounced 27 June 2005 10:00 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 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 E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address Church Street Tenbury Wells Worcestershire WR15 8BP 01584 810249 01584 810249 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Chantry Retirement Home Ltd. Vacant CRH 28 Dementia - over 65 Old age Physical disability - over 65 28 28 28 Category(ies) of DE(E) registration, with number OP of places PD(E) The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration Date of last inspection 23 November 2004 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 home was purchased by Chantry Retirement Homes Limited, in March 2004, and the directors are Mr Sefudin Hussein and Mrs Tasnim Ghiawadwala. The home has been without a care manager for over 12 months, and the deputy manager, who has many years’ experience working at The Old Rectory, has been managing the home with the support of the directors. A new care manager has recently been appointed, and is awaiting registration. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine, unannounced inspection, was to check on any previous requirements and recommendations, and to monitor care provision very thoroughly, which was considered necessary on this occasion, owing to the long term absence of a registered care manager. A new care manager had recently been appointed, and time was spent discussing the present situation at The Old Rectory, and also proposals for the future management of the home. Service users and staff were consulted about their experiences of living and working there, and every one was very positive in their comments. Visitors and professionals who were at the home on the day of the inspection 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 staff who were interviewed were 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 initial impression gained is that the home is well maintained and cared for, and that it is comfortable 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 and their families. The standard of the catering at the home also attracted very positive comments, and food was a major topic of conversation. The regular outings in the minibus, and the varied programme of activities, also contributed specifically to the things that were well done at the home. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Review and amend documentation, and policies and procedures, and provide relevant information to service users. Comply, in a timely manner, with the requirements and recommendations made – 12 requirements and recommendations had not been met since the previous inspection. Improve communication with the Commission, in respect of notifications, and also the reasons for failure to comply. Maintain equipment in good working order, and repair or replace items that are dysfunctional, without undue delay. Improve recruitment procedures, and the records relating to staff employment. Develop a training programme for staff, and provide the required accredited training. Introduce formal supervision procedures. Implement quality monitoring systems. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 7 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 E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 standard(s) 1,2,3,4 & 5 The Statement of Purpose, and Service Users Guide, do not accurately reflect information about the home, to enable a prospective service user to make an informed decision about their future care needs. The assessments undertaken prior to admission, are sufficiently detailed to ensure that the home is able to meet the identified needs of service users. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 10 EVIDENCE: A Statement of Purpose and a Service Users’ Guide are in place, and provides some information about the home for prospective service users. These documents were to have been amended, 12 months ago, to reflect the change in ownership of the home, but remain outstanding. An information booklet is available, together with a ‘flyer’, but these do not ensure compliance with the legislation. These documents, together with a copy of the Terms and Conditions of Residence should be completed, and a copy sent to the Commission, without further delay. The files of several residents were seen, and it was noted that the assessments undertaken prior to admission are satisfactory, and are used to form the basis of the initial plan of care. A Community Care Assessment is also on file. Discussions with residents and relatives confirmed that their needs are being met. Evidence was also provided, in the observations made of the responses of staff to the individual needs of service users. Comments were all positive about the care provided at The Old Rectory. A satisfactory admissions procedure has been produced, and the process was discussed with the Acting Care Manager. The manager or deputy visit prospective service users at home or in hospital, following the initial referral. A visit to The Old Rectory is encouraged, prior to making a decision about their future care needs, and they are also invited to stay for a meal. A trial stay may be arranged, if this is preferable. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 standard(s) 7,8 &10 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 privacy and dignity of service users was respected, and the atmosphere throughout the home was one of mutual esteem and regard. The staff have a good understanding of the needs of service users, and offer care in a way that encourages and promotes their independence. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 12 EVIDENCE: A comprehensive system of care planning is being introduced at the home, but ha not yet been implemented. The acting care manager has been developing the individual plans, and several were checked during the inspection. Improvements were evident, although all the personal details of residents had not been completed fully. 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. Tippex must not be used on formal documents. The health and personal care needs of residents are monitored and the home is well supported by the Primary Health Care Team. Specialist treatment could be accessed, and the advice of the continence nurse is sought when necessary. Risk assessments are completed, and details recorded when intervention is required. The need for nutritional screening to be undertaken, tissue viability to be assessed, and a record of the weight of service users to be maintained, was discussed with the Acting Care Manager. The need for sit on weighing scales has been identified, and arrangements are in hand for these to be purchased. Evidence to indicate that residents are treated with dignity and respect was observed in the way staff interacted with them, and was also confirmed in discussions with service users themselves. Everyone confirmed their satisfaction with the care provided, and considered they were very well looked after. Visitors were equally positive about the care provided to their relatives and friends. The following remarks were made by residents and their relatives: • • • • • • • • • • Staff are very caring and helpful Everyone is approachable The staff cannot do enough for me It’s absolutely ideal here The food is wonderful Things are better since the new manager came Everything is just fine This must be one of the better places to live I have no complaints at all I wouldn’t want to be anywhere else The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 standard(s) 12,13 & 15 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. Their wishes and preferences 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. Nutritious and wholesome food is provided, with a varied menu, but a record of the food provided to each individual service user is not maintained, therefore it is not possible to determine whether the diet is satisfactory for everyone. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 14 EVIDENCE: Service users confirmed they are able to choose how they spend their time. Various activities are available both within and outside the home, although some people prefer to stay quietly in their own room. The home employes an activities organiser who advised that recent activities have included, scrabble, bingo, shopping trips to town, in-house entertainment and ‘knitter-natter-reminiscence’. A rehabilitation therapist was visiting the home today, and several residents enjoyed some gentle exercises. One resident, of very advanced years proudly demonstrated touching her toes! ! The home has a minibus to take the more adventurous a little further from home, and they visit various places of interest or just go for a ride, e.g. a safari park, go for a picnic or a fish & chip tea, call at a garden centre. A recent request to go to the Elan Valley is also being considered. The home is very much part of the local community, and the involvement of family and friends is actively encouraged. Fund raising activities are organised, and have included a coffee morning, a garden fete and a strawberry tea. 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 daily menu was posted on the notice board. A four-week menu plan, indicated that a good variety of food was available. Special dietary requirements can be provided and currently include 3 diabetic diets. Many favourable comments were made regarding the standard of the food at the home, although it was suggested that a limited amount of fresh meat is being offered. The acting manager said that a review of the arrangements regarding the provision of food at the home was to be reviewed. A record of the food provided to individual service users is not being maintained at the home, and the importance of this was discussed with the acting care manager. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 standard(s) 16,17 & 18 The home has a satisfactory complaints procedure, and service users feel able to express their views and opinions, and know that they will be listened to. Training for staff has provided them with an understanding of the many aspects of abuse, and ensures the provision of a safe environment, where service users are protected. The absence of appropriate policies and procedures relating to the Protection of Vulnerable Adults is placing service users at possible risk of harm or abuse. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 16 EVIDENCE: A satisfactory complaints procedure has been produced and is accessible to residents and their families. A commitment to resolving any concerns at the earliest possible time has been made by the management of the home. There have been no recent complaints made to the home or to the Commission. The legal rights of service users are considered to be the same as if they were living in their own home. Postal voting arrangements are in place for all who wish to be involved. The policy on adult protection at the home, does not relate to the new management of the home. A review of these procedures was to have been undertaken 12 months ago, and a copy submitted to the Commission on completion, but this remains outstanding. The Protection of Vulnerable Adults (POVA) guidance has not yet been implemented at the home. A copy of this procedure should also be submitted to the Commission. Training has been provided for staff, to increase their awareness of the many aspects of abuse, harassment and bullying, and to ensure they are familiar with the procedures. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 standard(s) 19,20,21,22,23,25 & 26 The premises are suitable for their purpose. The building is well maintained, the standard of cleanliness was satisfactory, and the décor and furnishings in good condition, providing a very comfortable and homely environment for service users. The safety of service users and staff is now being compromised by the failure of the Proprietor to ensure that appropriate maintenance, and regular servicing of equipment is undertaken, and that the radiators and pipe work throughout the home are guarded. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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. 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. There are four bathrooms throughout the home, with provision on each floor. A bathroom on the ground floor has been out of action for over a month. The need to initiate repairs to essential equipment without undue delay was discussed with the acting care manager. A refurbished bathroom is fitted with a Parker bath and also has a separate shower cubicle. The shortfall of separate toilets is offset by the en-suite facilities provided in nine bedrooms. Throughout the house there are seven toilets plus a staff toilet. There are five bedrooms large enough for double occupancy, although two are being used as single rooms, and agreement has been reached with the Proprietor that this arrangement should continue. Service users in double rooms should have made a positive choice to share with each other, and a record kept of this arrangement in their individual care plans, but no evidence of this was found. Residents’ rooms are well ventilated and centrally heated with each radiator having an individual thermostat, but guarding of the pipe work/radiators has not been undertaken, as agreed by the Responsible Individual, and could present a serious hazard to service users. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 30 The staff team is now more stable, and staffing levels are being maintained at an adequate minimum level to meet the needs of service users. Many staff are experienced and competent in their work, and some training is being provided, which, with the continuing commitment to NVQ training should ensure the appropriate delivery of care. Recruitment procedures are in place, although these need to be more robust, and be implemented more thoroughly to ensure that service users are fully protected. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 staff awake, and one sleeping. In addition catering, domestic and maintenance staff are employed at the home, together with an activities organiser. The changes in the ownership arrangements at The Old Rectory, initially created a less stable staffing situation, and several staff subsequently resigned, although the situation is now more settled. Several staff were interviewed, and confirmed they enjoyed their work, although they felt they had less time to be ‘carers’ now. They explained that there seemed to be so many other things to do, that they could not spend so much time with residents. The Home has shown a commitment to NVQ training, and has exceeded the requirement that 50 of staff are trained to NVQ Level 2, by 2005. 8 staff have achieved the NVQ Level 2 in Care award, and a further 3 staff are doing this training. In addition, 3 staff are working towards Level 3. These achievements are commendable. Recognition of achieving these qualifications is reflected in the rates of pay for staff working at the home. A recruitment and selection procedure is in place, but is not always followed for newly appointed staff. Several staff files were checked and these did not all contain the required documentation, as listed in Schedule 2 of the Care Homes Regulations 2001. The application forms should all request information relating to the Rehabilitation of Offenders Act 1974, and the declaration should be signed. Several members of the staff team at The Old Rectory have many years experience in the care of older people. Induction training is given to new staff, but foundation training, in line with the National Training Organisation specification, has not yet been implemented. In addition, all staff do not have an individual training assessment and profile. Some training has been organised during the last 6 months, and included, infection control, medication, abuse awareness and moving & handling, but a review of the training needs of staff has not yet been completed. A staff training programme still has to be produced, and this now needs to be expedited, with a copy submitted to the Commission on completion. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,36,37 & 38 The absence of a registered manager for the past year, has had an adverse affect on the smooth running of the home, although the previous long-standing stability at The Old Rectory, and the experienced and cohesive staff group, has ensured that satisfactory standards of care have been maintained. There is no quality assurance system in place to ensure that the home is run in the best interests of the service users. Arrangements for the formal supervision of staff do not ensure that staff are able to understand fully their role within the home, or that career development needs are identified and met. The best interests of service users and staff are not safeguarded by the poor standard of record keeping, and the absence of appropriate risk assessment in respect of all safe working practices. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 22 EVIDENCE: A new care manager has been appointed recently at The Old Rectory, and an application for registration has been submitted to the Commission, which is currently being processed. The home has been without a registered manager for over 12 months, and the deputy, Mrs Ann Rogers, has valiantly undertaken responsibility for the day-to-day running of the home, with some support from the Proprietor. A quality assurance system has not yet been introduced at The Old Rectory. The acting manager confirmed that she has been given responsibility for the task, and that this will be implemented in the near future. There was no evidence that the formal programme for the supervision and appraisal of staff, that previously was said to have been developed, had yet been implemented. The importance of staff being appropriately supervised was discussed with the acting manager. Records had previously been maintained to the required standard within the home, but some of records seen on this occasion were not satisfactory: • Regular reports have not been submitted to the Commission on the conduct of the care home, under the requirements of Regulation 26 • Regulation 37 reports have not always been notified to the Commission when appropriate • A detailed record of the food provided to service users has not been maintained Concerns were expressed to the acting manager that The Fire Risk Assessment for the home had not yet been completed, neither had risk assessments in respect of all safe working practices been undertaken. The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 2 2 2 3 1 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 x 1 x x 2 2 2 The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 24 YES 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 1 Regulation 4 Requirement The Statement of Purpose must be amended to include all the information detailed in Regulation 4 & Schedule 1, and a copy supplied to the Commission A Service Users Guide which includes all the information detailed in Regulation 5 & Standard 1 must be provided to all service users, and a copy supplied to the Commission The statement of Terms and Conditions of residence must be amended to include all the information detailed in Standard 2.2 A DETAILED plan of care must be drawn up WITH the involvement of each service user in accordance with the requirements of Regulation15 and Standard 7 (Timescale of 30/09/04 & 31/03/05 not met) A DETAILED record of the food provided for service users must be maintained (Previous immediate requirement not met) The procedures for responding to suspicion or evidence of abuse must be amended to reflect the Timescale for action 31/08/05 2. 1 5 31/08/05 3. 2 5 31/08/05 4. 7 15 30/09/05 5. 15 17 Immediate & ongoing 31/08/05 6. 18 12 & 13 The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 25 7. 21 & 22 23 8. 25 23 9. 10. 29 30 19 18 11. 33 24 12. 36 18 13. 37 26 14. 38 26 15. 38 13 current management of the home, and a copy submitted to the Commission. Equipment provided at the home must be maintained in good working order - repairs to the water boiler & bath must be undertaken without delay Exposed pipe-work and radiators in service users’ rooms must be guarded or have guaranteed low temperature surfaces (Timescale of 31/03/05 not met) Recruitment procedures must be implemented in line with the requirements of Schedule 2 All members of staff must receive foundation training to National Training Organisation specification within 6 months of appointment to their post.(Previous immediate requirement not met) A quality assurance system must be introduced in accordance with the requirements of Regulation 24 & Standard 33 (Timescale of 31/03/05 not met) Care staff must receive formal supervision at least 6 times a year, and this must include all aspects of practice, philosophy of care in the home and career development needs. Notification must be made to the Commission of the occurrence of all accidents, injuries, illness and incidents, in accordance with Regulation 37 and Standard 38. A written report of the monthly visits to the home, on behalf of the Registered Provider, must be prepared, and copies supplied to the Commission The health and safety of service users must be promoted by undertaking risk assessment in E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc 31/07/05 30/09/05 Immediate & ongoing Immediate & ongoing 30/09/05 31/08/05 Immediate & ongoing Immediate & ongoing 30/09/05 The Old Rectory Version 1.30 Page 26 respect of all parts of the home to which service users have access, any activities in which service users participate and for all safe working practices (Timescale of 31/03/05 not met) 16. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 4 8 18 Good Practice Recommendations A copy of theamended admissions procedure, and other documents as they are updated, should be submitted to the Commission on Nutritional screening, tissue viability assessments, and the weight of service users should be undertaken on admission and at regular intervals thereafter A policy and procedure should be produced 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 Consideration should be given to the provision of a conservatory in order to further improve facilities for service users Consideration should be given to the provision of a dedicated hairdressing facility for service users Consideration should be given to improving the ratio of single/double rooms within the home A record should be maintained to confirm that service users who occupy a double room have made a positive choice to share with each other A copy of the training programme for staff should be submitted to the Commission when completed. An individual training and development assessment and profile should be provided for all staff 4. 5. 6. 7. 8. 9. 20 20 23 23 30 30 The Old Rectory E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 27 Commission for Social Care Inspection The Coach House John Comyn Drive Droitwich Road Worcester WR3 7W 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 E52 S52033 The Old Rectory (Tenbury) V224556 270605.doc Version 1.30 Page 28 - 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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