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Inspection on 31/10/05 for The Old Rectory

Also see our care home review for The Old Rectory for more information

This inspection was carried out on 31st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff have a positive relationship with residents, relatives and each other and this is reflected in the care provided. The providers work hard to provide a homely atmosphere and improve where ever possible.

What has improved since the last inspection?

There has been little improvement since the previous inspection. A number of areas were highlighted at the previous inspection regarding the environment; redecoration, new carpeting, new bedroom furniture and radiator/pipe covers. Wardrobes were light and could easily be pulled over, therefore need to be fixed to the wall to prevent injury. The provider has planned to address these once the extension has been registered with the CSCI.

What the care home could do better:

As stated in the previous inspection care files need to have more information documented relating to the service users in order to ensure that all of their needs and wishes are met. The manager needs to consult with the service users and or relatives, when preparing assessments of need and care plans. The terms and conditions of residence should be completed and signed. Medical needs of service users need to have a care plan in place to address these needs.The medication cupboard should be locked when administering medication away from the cupboard. The inspector was not able to examine staff files as the manager was not on duty therefore the requirements made at the previous inspection have been documented within this report and need to be addressed. The manager should keep a clear record of all training completed by staff and ensure that their training is kept up to date. The manager does not appear to have addressed issues highlighted within the previous inspection, she must do this within the timescales set to avoid enforcement action being taken.

CARE HOMES FOR OLDER PEOPLE Old Rectory, The The Old Rectory Care Home 70 Risley Lane Breaston Derby DERBYSHIRE Lead Inspector Vanessa Davies Unannounced Inspection 31st October 2005 10:00 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 DS0000033891.V262874.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. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Old Rectory, The Address The Old Rectory Care Home 70 Risley Lane Breaston Derby DERBYSHIRE 01332 874342 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) Mr Allen William Heath Ms Jacinta Barker Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: The Old Rectory is a detached property situated in the village of Breaston. It is situated 300/400 yards from the village centre and from a main bus route. The Home is registered to provide care for 21 older people within eleven single rooms and five double rooms on the ground and first floors. The first floor rooms can be accessed by both a shaft lift and stair lift.The Home was registered to a new provider in October 2002. The home has recently had an extension of 8 single bedrooms with en-suite facilities, the work is not completed as the provider intends to make changes to the main building, the extra bedrooms are awaiting registration. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and in conjunction with a site visit. The Registered Manager was not available on the day but the 2 providers were. Information was gathered by speaking with the providers, residents and a relative. What the service does well: What has improved since the last inspection? What they could do better: As stated in the previous inspection care files need to have more information documented relating to the service users in order to ensure that all of their needs and wishes are met. The manager needs to consult with the service users and or relatives, when preparing assessments of need and care plans. The terms and conditions of residence should be completed and signed. Medical needs of service users need to have a care plan in place to address these needs. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 6 The medication cupboard should be locked when administering medication away from the cupboard. The inspector was not able to examine staff files as the manager was not on duty therefore the requirements made at the previous inspection have been documented within this report and need to be addressed. The manager should keep a clear record of all training completed by staff and ensure that their training is kept up to date. The manager does not appear to have addressed issues highlighted within the previous inspection, she must do this within the timescales set to avoid enforcement action being taken. 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. Old Rectory, The DS0000033891.V262874.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 Old Rectory, The DS0000033891.V262874.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): 2,3,4 Continued limited information available within the residents files prevents staff from meeting their needs and potentially puts residents at risk of being admitted to a home unable to meet their needs. EVIDENCE: Standards 1,2,3 & 5 were assessed at the previous inspection in June 2005, standards 2 & 3 were not met and requirements were left. There was no evidence of any terms and conditions of residence in the 3 files examined. The inspector examined 3 residents care files and there were still a number of omissions, one file had no date of admission, the care plans had only been reviewed once since June 2005 and there was clear evidence of changes, which had not been addressed. The care plans continue to highlight the need but not how to manage or address the need. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 9 All files examined had limited information available about the resident. There was no evidence of input from residents or their relatives. One relative spoken with stated that the staff contacted him regarding appointments, he was not involved with his relatives care plans and was not sure whether his wife was, the file had no evidence of involvement. One file had no photograph of the resident. Old Rectory, The DS0000033891.V262874.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): Residents continue to be put at potential risk due to the lack of information to enable staff to meet their needs and the lack of responsibility over the safe administration of medication. EVIDENCE: All of the standards within this section were assessed at the previous inspection in June. As the manager was not available the requirements left at the previous inspection were not discussed and are carried forward into this report. Files examined, as stated in standard 3, remain the same and do not contain adequate information to ensure that needs can be met. On the day of inspection the drug cupboard was left open and unattended, this was brought to the attention of the provider. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 11 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): 12,14,15 As in previous standards, lack of information prevents staff from fully meeting the needs of the residents. A healthy varied diet ensures that residents are offered a wholesome diet supporting healthy eating. EVIDENCE: The inspector spoke with residents and they felt that there was enough for them to do, one lady stated that they had visits to the local pub which she enjoyed. The files do not evidence details of interests of residents, therefore preventing staff from meets social needs. Residents spoken with stated that they were supported to make choices and continue to have control over their lives. The home uses a key-pad door lock on the front door, residents who are able to access the community independently are able to use the key-pad, however there were no risk assessments or agreements with relatives for residents not able to use to keypad. The providers are currently doing the cooking between them, all meals are prepared daily with fresh produce. A record of menus is kept along with what is Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 12 actually eaten, residents spoken with confirmed that they have a choice at meal times and that the food was very good. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: Standard 16 was assessed and met at the previous inspection in June 2005. Standard 18 will be assessed on the next visit. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: All of the standards within this section were assessed at the previous inspection. The home is currently in the middle of having an extension completed and then refurbishment of areas of the main building, therefore requirements left at the previous inspection have not been met yet but there is a plan to address the issues and will be reassessed at the previous inspection. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: All of these standards were assessed at the previous inspection, requirements were made and need to be addressed. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 16 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): 32 Requirements not being addressed and residents living in the home without a thorough assessment of need, potentially puts residents at risk and questions the fitness of the manager. EVIDENCE: The previous report highlighted a number of requirements to ensure that residents were cared for appropriately, ensuring that their needs were met. The inspector assessed 3 care files and there has been no improvement, there are still a number of areas needing to be addressed in order to ensure that staff are able to meet the needs of the residents. A number of the requirements have been outstanding for over 6 months and need to be addressed. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 1 1 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 1 X X X X X X Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 18 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. Standard OP32OP7 1 OP32OP10 2 OP37OP32 3 OP32OP25 4 OP36OP32 5 OP32OP36 6 17 18 13.4 c 4.1c, 7, 9, 19, 12.4 a 13 Regulation Requirement Any activities in which service users participate are so far as reasonably practicable are free from hazards to their safety. (previous timescales 01.07.04 & 30.09.05) The privacy and dignity of service users must be respected at all times. (previous timescales 01.06.04 & 30.09.05) The Registered Person must maintain records detailed within Schedule 1 & Schedule 2. (previous timescale 30.09.05) The Registered Person must ensure that unnecessary risks to the health and safety of service users are identified and eliminated.(previous timescales 01.05.04) The registered person must ensure that all staff are appropriately supervised. (previous timescales 01.08.04 & 30.09.05) The registered person must maintain all records detailed in Schedules 3 - 4.(previous timescales 01.07.04 & 30.09.05) DS0000033891.V262874.R01.S.doc Timescale for action 15/12/05 15/12/05 15/12/05 30/11/05 30/12/05 31/12/05 Old Rectory, The Version 5.0 Page 19 OP38 7 13.4 a OP19 8 OP32OP3 9 OP32OP3 10 14.1 c 14.1 23.4 OP32OP7 11 OP32OP8 12 OP9 13 13.2 13.1 b 12.1 a OP9 14 17.1 a Sch 3 (3) The Registered Person must ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. (previous timescales 01.09.04 & 31.08.05) The Registered Person must ensure that the premises are kept in a good state of repair externally and internally.(previous timescale 01.05.05 & 31.10.05) The needs of the service users must be assessed by a suitably qualified person and a copy of the assessment is kept on file. (previous timescale 30.09.05) The registered person must ensure that there has been appropriate consultation regarding the assessment with the service user or representative. (previous timescale 30.09.05) The registered person must ensure that proper provision is made to promote the health and welfare of the service users. (previous timescale 30.09.05) Service users health needs must be fully met and where necessary advice and other services from a health professional gained. The registered person must make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. (previous timescale 30.09.05) The registered person must keep a record of details of any plan relating to the service user in respect of medication, specialist health care. (previous timescale 30.09.05) DS0000033891.V262874.R01.S.doc 31/12/05 28/02/06 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Old Rectory, The Version 5.0 Page 20 OP27 15 OP29 16 OP30 17 OP14 18 12.2 18.1 c i 19 Sch 2 (6,7) 17.2 Sch 4 (7) The duty roster of persons working at the home and whether the roster was worked, must be kept. (previous timescale 30.09.05) All staff employed must have two written references, a criminal record certificate on file and available for inspection. (previous timescale 30.08.05) All staff must receive training appropriate to the job they perform. Residents/representatives should be involved with decisions about their welfare. 30/11/05 30/11/05 30/11/05 31/12/05 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 3 4 5 OP7 OP17 OP19 OP27 Refer to Standard OP7 Good Practice Recommendations Daily notes on residents’ behaviour and experiences should be recorded on individual sheets to facilitate the review of care plans. Where intervals between entries on daily record sheets are longer than one week it is recommended that a summary entry is made for the week. The registered person should make herself and staff aware of the local ‘Age Concern Advocacy Scheme’. A written programme of routine maintenance and renewal of the fabric and decoration of the premises should be developed. The registered person should ensure, by means of a communication system, that the waking member of night staff can quickly communicate with the sleeping-in member of night staff. A record of mandatory and additional training undertaken by staff should be developed. A suitable model was discussed with the Manager. Staff should be provided with training on dementia. The registers persons should provide an annual DS0000033891.V262874.R01.S.doc Version 5.0 Page 21 6 7 8 OP30 OP30 OP33 Old Rectory, The 9 10 11 12 13 14 15 16 17 18 19 OP33 OP37 OP8 OP11 OP3 OP2 OP9 OP19 OP21 OP30 OP12 development plan for the Home. Staff should be expected to confirm that they have read and understood all the Home’s policies and procedures by means of a recorded signature and date. The Manager should regularly monitor the standard of residents’ records and show evidence of this by entering her initials on these records, or by some other means. The Manager should undertake a refresher course of training in the management of continence. Staff should receive training on bereavement The registered person should ensure that relevant documentation relating to the needs of service users is completed. The registered person should ensure that the terms and conditions of residence are signed by the service users or representative. The registered person should ensure that medication is documented accurately and signed by the GP. Carpets and decorating highlighted on the day of inspection should be replaced. The registered person should ensure that bathrooms are accessible to service users. The registered person should ensure that staff receive training in Fire safety, food hygiene, adult protection. Detailed information should be recorded regarding social, cultural and recreational interests of residents. Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Old Rectory, The DS0000033891.V262874.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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