Inspection on 05/03/08 for The Old Rectory

This inspection was carried out on 5th March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Rectory 04/03/09

The Old Rectory 29/11/06

The Old Rectory 22/11/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Old Rectory Chewton Hill Chewton Mendip Near Bath Somerset BA3 4NQ Lead Inspector Jane Poole Unannounced Inspection 5th March 2008 10:00 The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Old Rectory DS0000064624.V360111.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 Adults 18-65. 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 DS0000064624.V360111.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address Chewton Hill Chewton Mendip Near Bath Somerset BA3 4NQ 01761 241620 01761 241497 michelle@bradburyhouse.com 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 Neil Bradbury t/a Bradbury House Organisation ** Post Vacant *** Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users who have concurrent mental health needs may be admitted. 29th November 2006 Date of last inspection Brief Description of the Service: The Old Rectory is registered to provide a service for ten younger adults who have a learning disability. The service aims to support people who have relatively high needs including those who have Autistic Spectrum Disorders. The service is located in a large substantial house in the rural village of Chewton Mendip. The cathedral city of Wells is approximately 6 miles away and the city centres of Bath and Bristol are within travelling distance. There is a village shop across the main road. The home provides accommodation on three floors. The ground floor provides a lounge, dining room and activities/games room. There are two kitchens. The first is the house kitchen, which provides meals for the home. The second kitchen is accessible, with staff supervision, to the people living at the service. This kitchen is used to develop life skills. In addition to the living accommodation there are a range of staff areas including meeting room, administration office and staff office on the lower floor. The bedrooms are located on the upper floors. All the bedrooms are large and have en-suite facilities. There are three bathrooms, one of which has a spa bath. There is a staff area predominantly used by staff for night supervision. Additionally there is separate self-contained staff accommodation. The service would not be suitable for people with a physical disability who could not access the stairs, as there is no lift to the upper floors. There is an accessible garden to the front of the house and a courtyard area to the rear. Bradbury Homes Ltd owns the home. There is a manager in post but they are not yet registered with the Commission for Social Care Inspection. Fees at the home are assessed on an individual basis. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. This inspection was carried out by one inspector over a period of 7 hours. During this time the inspector was able to meet with people living and working at the home, observe care practices, tour the building and view records. At the time of the inspection there were 7 people living at the home. Some people are unable to fully express their views. Everyone seen appeared content and comfortable with the staff and their environment. Prior to the inspection the manager completed an Annual Quality Assurance Assessment. This gave some information about how the home feels they have improved in the last 12 months, plans for the future and numerical information about people living and working at the home. 4 members of staff, 2 people living at the home, 1 healthcare professional and 1 relative completed questionnaires prior to the inspection, some of their comments have been incorporated into this report. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: The home has a relaxed and friendly atmosphere; people living there appeared comfortable in their environment. The home supports people with complex needs but it was apparent that staff assist people to be as independent as possible by helping people to learn and develop independent living skills including self advocacy. Care plans are very personal to the individual and give clear guidelines to enable staff to assist people in their preferred way. Staff spoken to demonstrated a good knowledge of each person and were enthusiastic about their roles. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 6 Everyone living at The Old Rectory has a weekly activity programme and is supported by staff to take part in leisure and educational activities. Food in the home is of a good quality and the menu is adjusted each week to take into account peoples specialist needs and their choices. Staff were very happy with the training provided and all spoken to stated that training was relevant to their role and enhanced their skill base. There is a clear management structure in the home meaning that there is always a senior member of staff on duty throughout the day. The relative/carer who completed a questionnaire prior to the inspection wrote “we are more than happy with the care they give.” What has improved since the last inspection? What they could do better: Recruitment practices in the home require improvement to ensure that they fully protect people living at the home. At this inspection it was noted that The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 7 some staff had begun work without all required checks being obtained. Although risk assessments were in place they were generic and not personal to the member of staff. All new staff must have an initial Protection Of Vulnerable Adults (POVA First) check before they begin work in the home. The statement of purpose needs to be up dated to ensure that it fully reflects the service offered and what is included in the basic fee. The laundry is located in an outbuilding. The floor and walls are not impermeable and therefore not easy to keep clean. To promote good infection control practices the whole area needs to be deep cleaned and redecorated to ensure that a good standard of hygiene can be maintained. Currently one person living at the home self medicates. Staff need to record when medication is handed to this person to ensure that there is a clear audit trail. Medication training for staff should also be recorded. At the time of the inspection the comprehensive fire risk assessment was not easily available in the fire log. The certificates of insurance and registration were out of date. 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. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people wishing to move into the home have their needs fully assessed and are able to spend time at The Old Rectory before making a decision to move in. The Statement of Purpose does not give full up to date information about the management of the home or what is included in the basic fee. EVIDENCE: No one has moved into The Old Rectory since the last inspection carried out in November 2006. The area manager stated that the home has a clear admissions policy that includes liaising with relevant people and a full assessment of need. The inspector saw evidence that people visit the home on many occasions before making a decision to move in on a permanent basis. Both residents who completed questionnaires prior to the inspection stated that they received enough information about the home before they moved in. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 10 The contract of residence states that the first four weeks of a persons’ stay is a trial for the benefit of both parties, but this period can be flexible dependant on individual need. The home has a statement of purpose which sets out what is included in the fee and what additional items people will need to pay for from their personal allowance. The statement of purpose given to the inspector on this visit gives the name of the last manager. It also states that telephone calls are included in the fee but it was noted that one person living at the home had been charged for phone calls from their personal allowance. The statement of purpose needs to be up dated to ensure that it reflects changes made in the home and gives accurate information to people living there and to their representatives. People living at the home have contracts of residence in pictorial form and the inspector viewed two of these. Neither of the contracts seen included the fee level. All placement fees and contract details are held at head office and can be made available to relevant people. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are individual and give clear guidance for staff. Everyone has a personal activity programme designed around their needs, interests and abilities. EVIDENCE: The inspector viewed two care plans. Both were very personal to the individual and gave clear information to enable staff to assist people living at the home in their preferred way. Care plans gave evidence that they are reviewed every six months and amendments are made as necessary. There was evidence in the care plans that people are encouraged to maintain and develop independent living skills in line with their abilities. Staff spoken to said that they were encouraged to read care plans when they began work at the home and that their views were taken into account at reviews. Throughout The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 12 the day it was observed that staff had a good knowledge of people living at the home and their needs. Service users are encouraged to make decisions about their day-to-day lives and some people take part in self-advocacy sessions. Both of the people living at the home who completed questionnaires answered YES to the questions “Can you do what you want to do during the day, evening and at the weekend?” Everyone has a weekly activity programme and staff gave evidence that people living at the home are able to choose and make decisions about how they spend their time. All programmes seen were very personal to the individual taking account of their likes and abilities. In order to assist people to take part in decision-making in the home service user meetings are being introduced with the first meeting planned for next week. Risk assessments have been completed and these outline the reasons for any restrictions placed on people living at the home. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Meals in the home are good quality and meet the needs and wishes of individuals. People living at the home take part in a wide range of activities within the home and the wider community. Staff assist people to maintain links with family and friends. EVIDENCE: People living at the home are encouraged to take part in daily tasks around the home. In addition to the main kitchen there is a small kitchen where staff assist people with food preparation and basic cooking skills. Staff spoken to stated that they helped people to tidy and clean their personal rooms and do The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 14 their laundry if appropriate. One person has a self contained flat within the home which has its own small kitchen facility were drinks and snacks can be made. The Old Rectory is part of the Bradbury House organisation, which owns other homes in the area and a large farm located about two miles away. People living at The Old Rectory are able to access the farm for day activities. Everyone has a weekly activity programme which is individual to them and encourages people to learn skills and pursue their interests. Activity programmes show that people are accessing community facilities for leisure and education. Two people attend college courses locally and staff offer support where needed. The home has two vehicles and one person told the inspector that they use public transport to access nearby towns. Visitors are welcome at the home at all reasonable times and many people enjoy trips out and short holidays with friends and family. On the day of the inspection one person went out to lunch with their family. All bedrooms are a good size and have comfortable areas to sit in if people choose to spend time on their own. There is access to TVs in communal and private areas. There is also a games/art room which people can use to play pool, listen to music or take part in arts and crafts. A full time cook is employed who devises the menus on a weekly basis. The main meal of the day is in the evening when everyone is at home and there is a lighter meal at mid-day. The inspector was invited to have lunch. The food was home made, well presented and of a good quality. The staff, particularly the cook, has gone to great lengths to ensure that one person who requires a special diet is able to have a full and varied diet which meets their particular needs. A dietician has provided training to all staff and a picture reference guide has been created. The care plan shows that food and behaviour is closely monitored for this person. Another person living at the home is able to adjust the set menu on a weekly basis to ensure that the meals served are in line with their wishes. Menus are displayed outside the main kitchen and changed weekly. Throughout the day it was observed that staff and people living at the home interacted in a friendly manner creating a relaxed atmosphere. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have access to healthcare professionals according to their individual needs. The home needs to improve their recording practices for people who self medicate. EVIDENCE: All bedrooms have full en suite facilities where people are able to carry out their personal care in private. Care plans show the level of support that people require with personal care tasks. In addition to en suites there are communal bathrooms including one with a spa bath. The home employs both male and female care staff giving people some choice about the gender of the person who assists with intimate personal care. The management team stated that they have good relationships with local healthcare professionals. Appointments with local healthcare professionals are The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 16 recorded and people are referred to specialists in line with their individual needs. Staff assist people to attend appointments outside the home. Monthly health checks are written and these give an overview of any health issues that have arisen during the month, appointments attended and weights. Staff have received training in mental health issues and autism to ensure that they understand and are able to respond appropriately to people living at the home. Care plans contain details of behaviours, which maybe displayed by individuals and the triggers and diffusion techniques that are personal to the person. The home uses a Monitored Dosage System (MDS) for medication and it was stated that all staff receive training from the dispensing pharmacist. Records of this training were not viewed at this inspection. The inspector viewed the Medication Administration Records (MARs) and noted that all medication was signed for when it entered the home and when it was administered. One person self administers their medication but a risk assessment in relation to this was not in the care plan or with MARs. The risk assessment was printed from the computer when requested. There are currently no records maintained of when medication is handed to the individual to self-administer and therefore no clear audit trail in respect of this persons medication. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure in place. The recruitment procedure needs to be improved to ensure that it minimises the risks of abuse to people living at the home. EVIDENCE: The home has policies and procedures in respect of recognising and reporting abuse, making a complaint and whistle blowing. The complaints procedure is displayed in the entrance hall and is in an accessible format for people living at the home. No complaints have been received since the last inspection. Staff were aware of the whistle blowing policy and the ability to take serious concerns outside the company. All staff receive training in the protection of vulnerable adults within the first 6 months of work and refresher training on an annual basis. It was also noted that this subject was discussed at a recent staff meeting. All staff also receive training in Non- Abusive Psychological and Physical Intervention (NAPPI) Staff were able to give evidence that they had a good knowledge of individuals and knew when behaviours may be indicating that they were unhappy about something. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 18 Both residents who completed questionnaires stated that they knew who to talk to if they were unhappy. Some of the people living at the home are unable to make decisions about all aspects of their care. Only one member of staff spoken to was aware of the Mental Capacity Act and the implications for assisting people with decision making. It is recommended that staff receive training in this area and that the code of practice is made available to ensure that staff are assisting people in the most appropriate way. The recruitment files of the three most recently appointed members of staff were viewed. All contained two written references and Criminal Records Bureau (CRB) checks. However all CRB checks had been obtained after the start date, two files had initial Protection Of Vulnerable Adults (POVA First) checks dated the day after the staff begun work but no POVA First was in place for one person. There is a generic risk assessment in the home for people working before full clearance has been obtained but these were not personalised to the individual and did not give information about how each person would be supervised. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building provides spacious accommodation but some areas would benefit from re-decoration to make it more homely in appearance. The laundry area does not promote good infection control practices. EVIDENCE: The Old Rectory is a large detached house set in extensive grounds. It is in the village of Chewton Mendip that has some facilities, such as a shop and public house. It is also on a public transport route with easy links to Wells and Bath. All areas of the home are fitted with a fire detection system that is regularly tested. There are three floors, all communal areas are on the ground floor and bedrooms are located on the first and second floors. Communal areas consist The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 20 of a large lounge, dining room and games/activities room. People have unrestricted access to the lounge and are able to access the other communal rooms with staff support. There is appropriate office and meeting facilities for staff. The inspector toured the building with a member of staff. Bedrooms are of an excellent size and had been personalised to reflect the needs and interests of their occupants. All bedrooms have en suite facilities and there are three communal bathrooms. Bedrooms and bathrooms were clean and fresh on the day of inspection. Since the last inspection some carpets in communal areas have been replaced and there are plans to make the building more homely. It was noted that some areas of the home were beginning to look tired and in need of redecoration in the near future. For example paper and paint in some corridors was peeling. The homes laundry is situated in an outbuilding. The walls and floor are not impermeable and paint was flaking from the walls. Some areas were not hygienically clean and there were no hand drying facilities for people using the room. The provider needs to ensure that the laundry can be kept clean to prevent the spread of infection. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are clear lines of accountability and responsibility within the home. Staff are enthusiastic about their roles and committed to providing a good service. Recruitment and supervision practices need to be improved to ensure that they adequately protect people living at the home. EVIDENCE: The home employs 12 care staff, many are working towards National Vocational Qualifications (NVQs) but no one has completed the award yet. A cook and cleaner are also employed and the home shares a maintenance manager with other homes in the company. During week day mornings there are five members of the care staff team on duty and a member of the management team. At weekends when people are not being supported to undertake activity programmes this reduces to 3. There The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 22 are a minimum of three members of the care staff team on duty in the evenings until 10pm and two waking night staff. There is always a senior member of staff on duty who co-ordinates the shift and offers support and guidance to less experienced staff. Four members of staff completed questionnaires prior to the inspection; In answer to the question “Are there enough staff to meet the individual needs of all the people who use the service?” Two members of staff answered USUALLY, one person said SOMETIMES and the other said ALWAYS. Staff work very long shifts which can include an afternoon shift, a night duty followed by a morning duty. Since the last inspection this practice has been reviewed and a risk assessment has been put in place to state that staff working in the morning after a waking night do not drive company vehicles, administer medication or involve themselves with people who may be presenting difficult or challenging behaviour. Staff spoken to said that these excessively long shifts were voluntary and that the risk assessment was adhered to. Currently the staff duty rota gives the timing of day shifts but the night shift is marked only as ‘wake.’ This means that the total hours of work for each member of staff is greater than that currently entered on the duty rota. It is recommended that actual hours of work are recorded. Staff spoken to were very happy with the support they received and the training in the home. Staff felt that training was appropriate to their work and increased their understanding and skill base. All Staff who completed questionnaires answered YES to the question “ Are you being given training which is relevant to your role?” One person wrote that the training sessions were “interesting and informative.” People said that it was a pleasant place to work and that there was good communication between the management and other members of staff. Staff were enthusiastic and demonstrated an obvious commitment to providing a high quality service to the people living at the home. All staff receive a structured induction and staff spoken to felt that this gave them the confidence and skills to work in the home. The inspector saw evidence of ongoing supervision in staff files. The recruitment files of the three most recently appointed members of staff were viewed. All contained two written references and Criminal Records Bureau (CRB) checks. However all CRB checks had been obtained after the start date, two files had initial Protection Of Vulnerable Adults (POVA First) checks dated the day after the staff begun work but no POVA First was in place for one person. There is a generic risk assessment in the home for people working before full clearance has been obtained but these were not personalised to the individual and did not give information about how each person would be supervised. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 23 There was no evidence in files seen that past convictions or police cautions were discussed or that individual measures were put in place to ensure people living at the home were fully protected. The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39 & 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager at the home is not yet registered with the Commission for Social Care Inspection. The management is open and approachable and encourages the views of people living and working at the home. EVIDENCE: The manager at the home has not yet applied to be registered with the Commission for Social Care Inspection. At the time of this inspection the manager was not at the home but the assistant manager was available throughout the day. The area manager was also available for part of the inspection. Prior to the inspection the manager The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 25 completed and returned an annual quality assurance assessment setting out what they felt the home did well and some plans for the future. Staff spoken to described the management team as open and approachable. People felt that their views were listened to and incorporated into the running of the home. There are regular staff meetings which are a chance to share information and ideas. Service user meetings are being introduced to ensure that everyone has an opportunity to influence the running of the home. The area manager stated that the company has recently implemented three monthly quality audits for all homes within the group. Records of these were not viewed at this inspection. Reasonable steps have been taken to ensure the health and safety of people living and working at the home. A maintenance manager is employed who works between The Old Rectory and other homes owned by the company. The home is fitted with a fire detection system. Records show that alarms and emergency lighting is tested on a weekly basis. Staff stated that they received regular training in fire safety. The homes comprehensive fire risk assessment was not available at this inspection. The electrical installation was tested on the 23rd March 2007 with a recommendation that it be re tested in a years time. All accidents and incidents are recorded and notified to the Commission if appropriate. Certificates of registration and insurance are displayed in the hallway. At the time of this inspection both were out of date. An up to date certificate of insurance has been forwarded to CSCI. The Old Rectory DS0000064624.V360111.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 Adults 18-65 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 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 3 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x x 3 3 x x 2 x The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 27 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 YA34 Regulation 19 Requirement The home must ensure that recruitment files contain items as listed in Schedule 2 of The Care Homes Regulations 2001. (Previous date of 31/12/06 not met.) No staff must begin work in the home until satisfactory initial checks have been obtained and supervision plans are in place. The statement of purpose must be up dated to ensure it gives correct information about the home. All medication handed over to service users to self-administer must be recorded. The registered person must ensure that the laundry area can be kept hygienically clean to promote good infection control practices. A manager must be registered with the Commission for Social Care Inspection. The registered person must forward a copy of the current insurance certificate to the CSCI. Timescale for action 14/03/08 2 YA1 4 (1)[b][c] 13 (2) 13 (3) 30/04/08 3 4 YA20 YA30 14/03/08 30/04/08 5 6 YA37 YA37 8(1) [a] 25 (2) [e] 30/06/08 01/04/08 The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA5 Good Practice Recommendations The home should review the contracts to ensure they contain the items as listed in Standard 5 of the National Minimum Standards. (Carried over from previous inspection) The home should consider ways of making some parts of the home more homely in appearance. (Carried over from previous inspection) The home should keep records of regular checks of the hot water from the showers, washbasins and bath to ensure that they do not exceed the recommended temperature of 44 degrees centigrade for baths and 43 degrees centigrade for showers. (Carried over from previous inspection) Staff should undertake training in the Mental Capacity Act to ensure that they are assisting people to make decisions in the most appropriate way. 50 of care staff should be qualified to NVQ 2 level. The duty rota should be written to reflect actual hours worked. 2 3 YA24 YA42 4 5 6 YA23 YA32 YA33 The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. Extracts may not be used or reproduced without the express permission of CSCI The Old Rectory DS0000064624.V360111.R01.S.doc Version 5.2 Page 30 - 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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