Inspection on 03/05/07 for The Old Rectory

This inspection was carried out on 3rd May 2007.

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

The inspector 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 26/04/06

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 Old Rectory, The Church Street Tenbury Wells Worcestershire WR15 8BP Lead Inspector Rachel McGorman Key Unannounced Inspection 3rd May 2007 10:30 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 Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 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. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Rectory, The 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 vacant post 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) Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 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. 26th April 2006 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 offer care, friendship and comfort in a family atmosphere, to maintain a high level of personal regard for each resident, with particular emphasis on quality of life, and to encourage them to enjoy life to their full potential. 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 acting manager is currently awaiting registration, and she is assisted by the deputy manager, together with Mr Hussein in the day to day running of the home. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection, was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, in relation to the stated aims and objectives, and to follow up previous requirements and recommendations. Preparation for the inspection included viewing previous reports, and documents relating to the home, and considering the various contacts made with the home since the last inspection. The annual quality assurance assessment (AQAA), has been submitted to the Commission. This is a detailed self-assessment document that provides updated information about the establishment, and how well the stated aims and objectives are met. The visit was unannounced and took approximately 6 hours, when some time was spent with service users, discussing with them what is like living at the home, and observing their interactions with staff. The care records of three service users were checked in detail for case tracking purposes, and the Medication Administration Records were also seen. Discussions were held with relatives and visitors to the home at the time of the inspection. During conversations with staff, comments were made about what it is like to work at The Old Rectory. Two staff files were also seen. The inspector was able to speak with the staff member responsible for the maintenance of the building, and to check the records relating to the servicing of equipment, and to health and safety matters. Discussions were held with the acting Care Manager, Mrs Maggie Hope about her role, and the day-to-day management of the home. The Proprietor, Mr Sef Hussein, who was also at the home during part of the inspection, provided information on matters relating to the business. A tour of the premises was undertaken, and the ongoing maintenance, various improvements that have been implemented and the future proposals for the development of the home were discussed with the management. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 6 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. Relevant information about the service, and what can be provided, is available to assist prospective residents and their families to make the right decisions about their future care needs. The approach of staff is very obviously caring, which is what they consider they are good at, and this was clearly confirmed by residents, their families, and visitors to the home, with very positive comments being made by everyone. A high standard of personal care is provided for each resident at the home, and the staff work well with other professionals and agencies, to help improve and maintain their health, with obvious benefit to residents. The policies and procedures relating to the administration of medication and the training provided for staff, help to ensure that residents are protected. The individual needs of residents are regularly reviewed and recorded, the families of residents are supported and their involvement with the home is encouraged, which contributes to the wellbeing of the people who use the service. Opportunities are available for everyone living at the home to do the things they enjoy, and they are able to choose, if they wish, to be involved in the many activities that are provided. Recruitment and selection procedures are followed, and the management is clear about the support, training and development for the staff it employs. Staff confirmed that they are given appropriate training opportunities. The building is maintained to a high standard, and everywhere is fresh and clean. The house gives the appearance of being well cared for, and it is nicely furnished, warm and comfortable, and safe and secure. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Complete the programme of guarding to all radiators throughout the home, for the protection of the people who live there. To ensure that the home is run in the best interests of the people who live there, the quality monitoring system should be further developed and implemented. Further amendments should be made to the documentation, to reflect the new care management arrangements at the home, and to confirm when the information was last reviewed, which should ensure that accurate information is available when required. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 8 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 summary of this inspection report can be made available in other formats on request. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information available to prospective residents, and the way in which the admission procedure is implemented, provide an appropriate introduction to the home, and also help people to make an informed decision about their future care needs. The pre-admission assessment provides relevant information about the prospective resident, and ensures that the home is able to meet their identified personal and healthcare needs. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 11 EVIDENCE: A statement of purpose has been produced, which together with the service users’ guide, provides prospective residents with information to enable them to make a decision about their future care needs. An Information Booklet provides some additional information about the home for prospective residents. A statement of the Terms and Conditions of residence is provided to each person on admission, and contains information about their occupancy in the home. The document reflects the rights and responsibilities of both resident and management in respect of the contract, and there is an expectation that both parties will sign to confirm acceptance. These documents are reviewed regularly, and will be amended to reflect the new management arrangements in due course, the inspector was told. The admission procedure recognises the need for a sensitive approach to be taken to the assessment process and to the introduction to residential care for a prospective resident. Two residents who were admitted to the home recently, both said they were given the opportunity to visit the home, and one person had been able ‘to try it out first’. They both felt that staff had ‘made things as easy as they could’, and that ‘everything had gone very smoothly’. The Care Manager or Deputy usually undertakes a pre admission assessment following the initial referral, and a visit to The Old Rectory is encouraged. The prospective resident is 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 a decision being made about future care needs. The admission procedure now includes a more detailed process for dealing with all assessments, including residents who are self-funding and also emergency admissions to the home. In addition a Community Care Assessment is obtained from the placing authority, prior to admission, to ensure that the identified needs of the prospective person can be met by the home. Relevant information was found in the residents files. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. Risk assessments are completed, to support service users in being as independent as possible. The policy and procedures covering the administration of medication ensure the protection of service users. The privacy and dignity of the people who live at the home is respected, and the atmosphere throughout the home was one of mutual esteem and regard. Staff demonstrated a good understanding of the needs of residents, and offer care in a way that encourages and promotes their independence. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 13 EVIDENCE: The individual plans of care for three residents were examined in detail, and evidence seen of further improvements in the process. Monthly reviews are completed regularly, and the content of the care plans is now more detailed. The involvement of the resident and their family or representative is also encouraged and recorded. Risk assessments are completed, in respect of mobility, moving and handling, and tissue viability, and the weight of residents is also monitored. The relevant documentation was seen in each care plan and also included the many activities of daily living for each individual. The daily log reflects how each persons day has been, and specific information is then transferred to the care plan, for example, if the resident went out or had visitors at home, or details of visits from health care professionals. The health and personal care needs of residents are monitored closely 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. There are several residents with urinary catheters fitted, and who therefore require regular attention from the district nurses. The Medication Administration Records were seen during the inspection, and had been completed to a satisfactory standard. A monitored dosage system is now in place and is being implemented appropriately. Records show that regular medication reviews are undertaken by the GP, and that training is provided for staff on the administration of medication. Evidence to indicate that residents are treated with dignity and respect was observed in the interactions of staff with them, and was also confirmed in discussion during the visit. The following comments were made to the inspector: • • • • • • • • • I couldn’t be anywhere better I wouldn’t change anything here I would tell them if things were not right I like going out and the minibus trips are very enjoyable. We usually go every week There’s always plenty to do here if you want to be involved I’m comfortable and content and there is always an immediate response to my ringing the bell Everyone is very caring although some staff have more time than others. By that I mean, some staff are good and some are very good I do as I please. I go to bed when I want and get up when I want, and I stay in my room when I want, or I go down to the lounge when I want I feel safe and secure here DS0000052033.V338593.R01.S.doc Version 5.2 Page 14 Old Rectory, The 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The social, emotional and spiritual needs of residents are identified, and various recreational opportunities provided to ensure their interests are fulfilled. The wishes and preferences of each person 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 the people who live there have complete freedom in regard to their contacts, both within and outside the home, which enables a good quality of life to be maintained. Residents are offered a choice of nutritious, wholesome and well-balanced meals that helps in maintaining their health and wellbeing. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 15 EVIDENCE: Residents living at The Old Rectory have complete freedom of choice in regard to their contacts, both within and outside the home, and they are enabled to make choices about all the activities of daily living, for example, when to get up or go to bed, and how to spend their day, or whether to join in the various pastimes. This was confirmed in conversation with service users and staff, and also in comments received from relatives, who were very positive about the home. Organised activities are regularly available, although some people said they preferred to stay quietly in their own room. The inspector met with the activities organiser, who is employed by the home for three days a week, specifically to work with residents, to ensure that those who wish are given opportunities for stimulation through leisure and recreational facilities. She works individually with residents, arranges some group activities, and also encourages involvement with the local community. The following is a list of recent activities that have been arranged: • • • • • • • • • • • Knitter/natter and reminiscence sessions Bingo Two residents are currently involved in doing jigsaws Art therapy in the form of painting and crayoning. Some residents are very talented and their work had been framed to create lovely pictures Evidence of glass painting was seen, and vases, candle pots and photo frames had been produced A fish and chip supper is regularly enjoyed Coffee mornings are arranged from time to time Board and card games, including scrabble are very popular Musical entertainment by an organist with audience participation Seasonal events are reflected in the programme which can also include spontaneous suggestions from residents Cards are produced to celebrate birthdays and anniversaries Today eleven residents went out for a drive in the minibus, and took fresh scones and flasks of tea with the intention of stopping for a picnic on the way. A good time was had by all, was confirmed by everyone on their return. The minibus trips on other occasions may visit various places of interest, stop somewhere for afternoon tea, or an ice cream, or just go for a scenic ride. Any special requests are also taken into consideration, such as a shopping trip, the inspector was told. The spiritual needs of residents are considered. A monthly service is held at the Home, and residents are enabled to attend church, if they wish. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 16 The home is very much part of the local community, and its proximity to the town centre is of benefit in this respect. The Old Rectory describes itself as having an open door policy. The involvement of family and friends is actively encouraged, and visitors said they are always made welcome. Several people were visiting the home today, with whom the inspector was able to have a chat, and who each confirmed their satisfaction with the home, and who were very complimentary about the care provided to their relatives and friends, and about the kindness of staff. The following views were expressed: • Staff are very helpful and friendly • I have no concerns about the care of my mother • There’s plenty of information available about the home and what goes on • We are included and involved in everything that happens here • The needs of all the residents are always looked after cheerfully • Mum has been extremely happy here • She has always felt ‘at home’ • Father decided himself he wanted to come here • The arrangements were handled well • Everything always seems to run very smoothly • They are very caring and professional people here Fund raising activities are organised, at which some items produced by residents are sold, and have included coffee mornings, a garden fete and a strawberry tea. Pupils from the local school also do community projects that involve residents at the home from time to time, and have done some ‘Art Classes’ with them. The Old Rectory has been awarded the Food Guard Award, for the standards maintained in respect of the catering arrangements at the home, and staff were proud of their achievement. The daily menu is posted on the notice board, and the four-week menu plan indicates that a good selection of food is available, which is varied to reflect seasonal changes and any specific requirements that may be requested. The special dietary needs of residents 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 risk assessment is also completed, for the protection of residents who suffer from diabetes, and a record of the food provided to each service user is maintained, to ensure that a suitable diet is taken by everyone. Lunch today looked very appetising, and consisted of turkey casserole, mashed potatoes and runner beans, or fish fingers, followed by jam sponge and custard. Comments about the food were all very complimentary. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure is circulated to all relevant people, and is implemented at the home in an open and efficient manner. The policy and procedures in place at the home relating to abuse, and the training provided for staff, should ensure the protection of the people who live there, and who may be vulnerable. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 18 EVIDENCE: A clear procedure for investigating complaints has been developed, and any issues are dealt with immediately, the inspector was told. Residents and their families confirmed that they felt confident that any concerns raised with the management of the home, would be listened to and addressed in an appropriate way. People felt that their views were welcomed, and they were aware of the procedure to be followed if they needed to voice any concerns. There have been no complaints about the service during the past year, but there were some pleasing comments recorded in the log, which included the following: • • • • • • This is a delightful place I have consistently observed the highest level of courtesy to residents from everyone These are very professional and caring people We are so pleased with the care and attention given to father Thanks for looking after my grandmother so well The service here is most efficient – thank you In addition, a resident had written a letter to the cook thanking her for the lovely Christmas dinner, and she also included the help, support and kindness given to her by staff. The home had previously been encouraged to record all comments made about the service and the care provided, to give a more balanced view of the service. The policy and procedures on adult protection at The Old Rectory have been amended, as previously requested, although further changes are now needed to reflect the new care management arrangements at the home. The inspector was assured that these amendments will be made, together with all the other documentation, when the care managers registration is confirmed by 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 questionnaire has also been produced for staff, to increase their awareness in relation to the guidance produced by Worcestershire County Council regarding the Protection of Vulnerable Adults. A policy and procedure in relation to staff who may be unsuitable to work with vulnerable people has now been introduced by the management of the home. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,25 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The 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 and security of the people who live there. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 20 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. Several people said, ‘how happy they are to be living at the home’, and one resident commented on, ‘how lovely and warm the home is’, and another person said, ‘how much they like their room’. The grounds, although not extensive, are accessible to residents. There are two pleasant lounges situated on the ground floor, and a large dining room, for the use of residents, all of which are furnished and decorated to a very high standard. Consideration is now being given to the possibility of adding a conservatory to one of the lounges, which would further enhance facilities for residents, but it is anticipated that the listed status of the building may cause some difficulties with planning permission. The inspector visited several bedrooms, and all were seen to be very comfortable, and furnished and decorated to a high standard. The bedrooms are well ventilated and centrally heated, with each radiator having an individual thermostat, to enable residents to adjust the heating. The guarding of two radiators remains outstanding, but this work is due for completion in the near future. Meanwhile risk assessments are in place. Emergency lighting is provided throughout the Home and a generator is available to maintain power supplies in the event of an electricity failure. The home is clean and fresh throughout and staff confirmed that they are familiar with the procedures regarding the control of infection, and that they have also been given training in health and safety matters. The inspector was told that there are no outstanding requirements following a visit to the home by the Environmental Health Officer in November 2006, and the cook confirmed how very pleased they had been with the standards that were maintained in the kitchen. A maintenance programme is in place at the home, and the inspector met with the member of staff with responsibility for the upkeep of the property. The records seen, confirmed that everything at the home is in good working order. A new spin dryer and vacuum cleaner have been purchased recently. Several areas have been upgraded as part of the ongoing programme, which has further improved facilities for people who live and work at the home. These include the development of a staff room, retiling the kitchen, redecoration of the dining room, the replacement of several carpets, fitting more handrails and relaying the patio. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team is now more settled, and staffing levels are being maintained at an adequate level to meet the needs of residents. Many staff are experienced and competent in their work, and ongoing training is being provided, which, together with the continuing commitment to NVQ training should ensure the appropriate delivery of care for the people who live at the home. Recruitment procedures are being implemented to a more satisfactory standard, which should ensure the protection of residents. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 22 EVIDENCE: The staff rotas indicate that staffing is maintained at a level that is appropriate for the needs of the people who live at the home, and this was confirmed in conversation with residents, who are very complimentary in their views about the staff and the care they receive. There is a minimum of three care staff 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 stable, and therefore able to more effectively respond to the needs of residents. Staff were observed by the inspector to deal very kindly and professionally with all residents, and there was evidence seen of their commitment to maintaining a good standard of care. The members of staff with whom the inspector spoke, confirmed that they enjoy their work, and all were very positive about being employed at the home, and also about the training opportunities they are given. Over 50 of the care staff have the NVQ Level 2 in Care, and one person is currently taking the award. Three staff have completed Level 3, and the acting care manger is a NVQ assessor. A further 5 staff are doing an NVQ, Level 2 in Hospitality. The Skills for Care induction is provided for new care staff, and a staff training plan has been produced in the form of a matrix, to record all the courses that each person has attended, and to identify any training that needs to be done. The records indicate that ‘core’ training has been provided for staff in health and safety, basic first aid, fire safety, basic food hygiene, and moving and handling. COSHH(Control of Substances Hazardous to Health) training has also been attended by several staff. In addition, some staff have attended care related training sessions on the administration of medication, dementia care and abuse awareness. The files of two recently appointed members of staff were inspected, and the correct procedures had been followed, in regard to recruitment and selection. Relevant information was recorded and appropriate documentation was in place, and included evidence of Criminal Record Bureau (CRB) checks undertaken prior to employment, the applicants CV, references, proof of identity, and training certificates that provided evidence of qualifications. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,37 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The acting care manager is very experienced, which will be of benefit to both residents and staff. The quality assurance system, when fully implemented, will ensure that the home is run in the best interests of the people who live there. The policies, procedures, and records maintained at the home, comply with legislative requirements, and therefore help to safeguard the rights of the people who use the service. The health, safety and welfare of residents and staff is promoted and protected in respect of all safe working practices. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 24 EVIDENCE: Following the resignation of the registered care manager several months ago, the Proprietor, Mr Sef Hussain has appointed Mrs Maggie Hope as the acting care manager. She has submitted an application to the Commission and is awaiting confirmation of registration as the care manager at The Old Rectory. The Deputy, Mrs Ann Rogers had again taken responsibility for the day to day running of the home, with support from the Proprietor, until a new manger was recruited. A Regional Manager had previously been appointed, with the intention of providing supervision to The Old Rectory, in the absence of the registered manager, but ill health resulted in her resignation. In addition, an Administrator had also joined the staff, to relieve the care team of some clerical tasks, but she has since Company. A quality assurance system has yet to be fully implemented at The Old Rectory. A user satisfaction questionnaire has been developed for residents, and a survey for relatives and friends to complete, together with one for visiting professionals, to seek their views and their experience of the service provided at the home, but the results have not yet been audited. The wishes of everyone living at the home, and the opinions of their families have always been taken into consideration by staff and the management of the home, and this was confirmed by everyone with whom the inspector was in contact, but a more formal and consistent approach is now required. A system for measuring how well the home succeeds in achieving the stated aims and objectives is needed, and the results audited and published annually. 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 as evidenced by the certificate. The management of the home confirmed that staff are not permitted to have any dealings with the financial affairs of the people who are living at the home. Arrangements are in place for their family or a representative to take responsibility, where a resident lacks capacity or does not wish to be involved. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 25 The best interests of people living at the home are safeguarded by the records and the policies and procedures that are in place. The records seen during the inspection are maintained to a satisfactory standard. A review of the policies and procedures is undertaken regularly, the inspector was told, but this could not be confirmed as all the documents are not dated. Copies are available for reference and information in the staff room. A health and safety policy and procedure is in place, and all staff are trained in safe working practices. The fire log indicated that fire safety checks are being carried out, with the required frequency, the fire risk assessment for the home is up to date and fire drills are undertaken. An emergency evacuation contingency plan has also been developed. Relevant contracts are in place, for the servicing and maintenance of equipment, hot water temperatures are controlled and regular checks undertaken, and a contract is also in place for Legionella testing. The Accident Books are completed to a satisfactory standard, and Regulation 37 Notifications, which require reports to be sent to the Commission of the death, injury or serious illness of a service user, or other events in the home, are made to the Commission, when appropriate. Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 26 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 3 3 X 3 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 X 3 3 Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 27 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 OP33 Regulation 24 Requirement A quality assurance system must be introduced in accordance with the requirements of Regulation 24 & Standard 33 Timescale for action 31/07/07 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 OP25 OP37 Good Practice Recommendations The programme of fitting radiator covers should be completed without further delay Further amendments should be made to all relevant documentation, to reflect the new care management arrangements and to ensure accurate information is provided about the service All documents should be dated to confirm when they were last reviewed 3 OP37 Old Rectory, The DS0000052033.V338593.R01.S.doc Version 5.2 Page 28 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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