Inspection on 28/01/05 for The Old Rectory Care Home

Care Home For Older PeopleThe Old Rectory Care HomeNorwich Road Acle Norwich Norfolk NR13 3BXUnannounced Inspection28th January 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment The Old Rectory Care Home Address Norwich Road, Acle, Norwich, Norfolk, NR13 3BX Email address pearlcare@yahoo.co.uk Name of registered provider(s)/company (if applicable) Pearlcare (Acle) Ltd Name of registered manager (if applicable) John Mills-Darrington Type of registration Care Home No. of places registered (if applicable) 34 Tel No: 01493 751 322 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (34) Registration number I550002056 Date first registered 14th May 2004 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 14th June 2004 YES NO 15/9/04 If Yes refer to Part CThe Old Rectory Care HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 328th January 2005 10:00 am Mrs Dorothy BinnsID Code074938Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr John Mills-Darrington Registered ManagerThe Old Rectory Care HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementThe Old Rectory Care HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of The Old Rectory Care Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.The Old Rectory Care HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Old Rectory is a period residence located in the small rural market town of Acle, mid way between Norwich and Great Yarmouth and close to the Norfolk Broads. There are shops, a weekly market, pubs and a church all within walking distance and there are bus and train services to Acle. The property has been purposefully adapted and extended to provide residential accommodation for up to 34 older people. There are 3 double and 28 single rooms and many have direct access into a well planned garden. The double rooms and 24 of the single rooms have ensuite facilities.The Old Rectory Care HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an unannounced inspection lasting about three hours. The requirements of the last inspection were discussed in detail with the manager and three service users were seen in their rooms. A discussion also took place with the senior carer about medication and issues relating to the care of those service users who require a lot of attention. Records and policies were also examined. Only some of the standards were inspected. Overall service users were very positive about the home and felt they were well cared for. They were very positive about the staff and felt that they did everything they could to make their lives comfortable. They wanted more activities but overall were quite content. The systems in the Home ensured that the health and safety of the service users was maintained. Care records could be better organised and have more about the interests and routines of the service users though detailed records such as fluid charts were held on those where extra attention was required. Policies and procedures were in place. There is a problem with staffing at the moment and the home is having to be maintained by the use of agency staff. The manager reports that recruitment is underway. Menus have been improved but a recommendation has been made for the menu board to be clearer to service users. How the Home fared against the standards is as follows: Choice of Home (Standards1-6) Only standard 3 was inspected in this section as these standards had been inspected last time. There is an initial assessment of the service users when they first come into the Home which includes information about their physical health, mobility and their personal care needs. There is also information from hospitals or previous placements. More could be recorded on the strengths and skills and interests of the service users so staff understand more clearly how to assist. This would lead into a care plan which currently is not organised. A recommendation has been made to review the care documentation. Standard 3 was partly met. Health and Personal Care (Standards 7-11) The care records were rather muddled. There was an assessment document though this could have been expanded. It was not clear what tasks the staff had to carry out though staff themselves were clear. The staff did record daily but there seemed to be some duplication with a monthly review. A recommendation has been made to have a clearer care plan and a coordinated approach to recording. There was plenty of evidence that service users were having access to community health facilities with a record kept on each file of the visits from the GP, district nurse as well as the chiropodist and dentist. Appointments at hospital were recorded. Staff also maintain fluid charts where appropriate and comments in the daily reports about the service users health. The Old Rectory Care Home Page 6 Two service users have pressure sores (one superficial) and their care is overseen by the district nurse, who was seen in the Home. One senior staff was seen by the inspector and was able to fully discuss the procedures for caring for service users who needed special attention. Medication systems were checked and found to be administered satisfactorily. Staff were correctly signing the records and identifying any drugs returned to the pharmacist. Appropriate storage was provided with double locking. Staff confirmed that they hasd received training from Boots Pharmacy. In terms of the delivery of care, the service users thought the staff were very good, very helpful and devoted. They felt they were dealt with appropriately and with dignity. The care was offered behind closed doors and they could enjoy privacy when they were assisted. Daily Life and Social Activities (Standards 12-15) Service users were very positive about the Home and thought the staff were wonderful. They thought the routines were flexible and they could wander around the home as they liked. They were disappointed about the lack of activities. This had been picked up by the inspector at the last inspection and a requirement made for improvement, but due to staff shortages, no progress has been made. The Home is still having to use agency staff and while that is happening it may be difficult to be organised about activities. However the effort needs to be made and a further requirement has been made for consultation with the service users about their own interests and what activities they would like to have provided. Contact with family is encouraged and visitors can be seen in private in the service users rooms. The menus and snacks were the subject of a requirement at the last inspection and choices on the menu have now been introduced. Snacks are reported to be available in the evening. However the service users were still not quite clear as to whether they had a positive choice and a recommendation for a clearer display of the menus for the day needs to be made. Standards 12 and 16 were partly met and standard 13 was met. Standard 14 was not inspected. Complaints and Protection (Standards 16-18) The complaints procedure was seen to be in place and a record kept of complaints received about the Home. This standard was met. Standard 17 and 18 were not inspected. Environment (Standards19-26) None of these standards were inspected. Staffing (Standards 27-30) From the rota provided at the inspection, the care hours were above the minimum required for the 31 service users accommodated. Catering hours were also satisfactory and the manager was supernumerary. Domestic hours were a little below the minimum required and the registered manager may wish to increase these. None of the other standards were inspected. Standard 27 was met.The Old Rectory Care HomePage 7 Management and Administration (Standards 31-38) Only three of these standards were inspected. The records were examined to see that one to one supervision was taking place on a regular basis and this was found to be the case in the staff files sampled. Some of the records required for regulation were checked and found to be in place. Fire, staff, accidents, care records and a record of visits by the provider were all in place. A requirement had been made at the last inspection for a record to be kept of all the events which are notifiable to the Commission under regulation 37. These include, deaths in the home, accidents, outbreak of disease and other matters. This record is now in place. Records and policies were also examined to see that the registered manager was ensuring the health and safety of the service users. Appropriate policies were in place and certificates and tests were up to date. Training for staff was also seen to have been provided in emergency aid and top up training on moving and handling was organised for February. In terms of physical safety, all radiators are covered and hot water temperatures controlled. Standard 36, 37 and 38 were met.The Old Rectory Care HomePage 8 Requirements from last Inspection visit fully actioned?NACONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)The Old Rectory Care HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The registered person must consult the service users about their interests and what activities they would like in the Home. Time for staff to provide stimulation is also required.116(2)(n)OP1231.3.05RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 OP7OP3 It is recommended that the assessment documents and care plans are reviewed to make them more detailed and coordinated. It is recommended that the menus are clearly displayed at the beginning of the day to enable service users to know they have a positive choice of food.2OP15* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10. The Old Rectory Care Home Page 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) NO YES NO YES YES NO NO NO YES NO YES NO YES YES NO NO NO NO NO YES 3 0 0 NO NO YES YES 23 0 28/1/05 10AM 3.5The Old Rectory Care HomePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.The Old Rectory Care HomePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/Evidence Not inspected on this occasionYES Standard met? 0The Old Rectory Care HomePage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 2 Key findings/Evidence Standard met? The assessment document has details of physical care but could have more information about the routines and interests of service users to help staff understand their personal strengths and the things which are important to them. This would then lead into a more active care plan with a clear understanding of what the service users can do and would like to do. Together with standard 7 it is recommended that the care plans/records are more detailed and coordinated. See recommendations. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? Not inspected on this occasionThe Old Rectory Care HomePage 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Not applicableThe Old Rectory Care HomePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? Care records did not have a clear care plan though did contain assessment information, covering mobility, health, personal care, behaviour and more. Staff did record daily and the care was reviewed monthly. Medical matters were dealt with separately. The records were somewhat disorganised and the entries in the record did not always show the consequences of what happened. Or an answer would have to found in a different part of the record. A more cohesive approach was recommended and the manager agreed to review the presentation of these records. See recommendations. The standard was partly met Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence The standard was met 1 2 Standard met? 0The Old Rectory Care HomePage 16 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The standard was met.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The standard was metStandard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? Not inspected on this occasionThe Old Rectory Care HomePage 17 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? Service users felt the routines were quite flexible and they could go to bed when they liked. There was some flexibility in the bathing routine with one person saying they had a shower every day, another person preferring a weekly bath. Service users were also free to move around the home as they were able and use the lounges or their rooms for sitting in. The one area where they thought there could be an improvement was in the provision of activities. All three service users seen said there was very little provided apart from the odd entertainer coming in. Staff did little in the way of organising activities. They thought this was the one shortfall of the Home. The inspector is aware that the home has been short staffed and using agency staff. However it is essential that service users are able to enjoy some stimulation or to be taken out for walks. This had been a requirement of the last inspection but not enough has been arranged. It is required that staff are given time for such activities and a further timescale is given. See requirements. The standard was partly met. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The standard was met.The Old Rectory Care HomePage 18 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? It had been a requirement of the last inspection to improve the food offered in the Home and to provide a more choice. The manager confirmed that there was now a choice at the main meal and they were offering a cooked choice at teatime as well as sandwiches. The cook was seen and confirmed the choices on the menu on the day of the inspection. A schedule was also seen for those who wished early teas, and what evening drink was required. A cooked tea as well as sandwiches are also reported by the manager to be offered. A snack in the evening is also available. The service users seen said they enjoyed their food. They thought there was a set menu but that you could receive an alternative if you wanted. They said tea was mostly sandwiches though one person knew there was soup on the menu today. There seemed to be a division between what the service users saw as on offer and what the staff thought there was available. A menu board was displayed outside of the kitchen in the corridor but was clearly not being seen by everyone. It is suggested that the Home makes it more apparent to service users about the choices available. A notice board with large print setting out the menu for the day could be there at breakfast time so service users have time to decide and are well informed. See recommendations. Overall though there was an improvement in the choices available. The standard was partly met.The Old Rectory Care HomePage 19 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 3 0 2 1 0 1 100 3 Key findings/Evidence Standard met? The complaint sent to the Commission was in fact dealt with by the Home and not upheld. A record is appropriately held and a complaints procedure was in place. The standard was met.The Old Rectory Care HomePage 20 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Not inspected on this occasion Standard met? YES 0 0The Old Rectory Care HomePage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasionThe Old Rectory Care HomePage 22 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasionThe Old Rectory Care HomePage 23 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 28 24 3 3 26 27 1 1 20 Key findings/Evidence Standard met? The above figures were taken from a previous report. This standard was not inspected.The Old Rectory Care HomePage 24 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? Not inspected on this occasionThe Old Rectory Care HomePage 25 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence The standard was met. X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 3The Old Rectory Care HomePage 26 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence Not inspected on this occasion X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasionThe Old Rectory Care HomePage 27 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? Not inspected on this occasionThe Old Rectory Care HomePage 28 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Not inspected on this occasion Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? The standard was metThe Old Rectory Care HomePage 29 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Not all the records required for regulation were see but those which were requested were in place and properly maintained unless stated in the particular standard. The standard was met.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? On the evidence of what was seen the standard was met.The Old Rectory Care HomePage 30 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorDot Binns N/ASignature Signature SignatureRegulation Manager Roger Hadingham Date Public reportsIt should be noted that all CSCI inspection reports are public documents. The Old Rectory Care Home Page 31 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 28th January 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.The Old Rectory Care HomePage 32 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 16th March 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here The Old Rectory Care HomePage 33 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.The Old Rectory Care HomePage 34 The Old Rectory Care Home / 28th January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000061106.V209547.R01© This report may only be used in its entirety. 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