Inspection on 30/07/07 for The Old Rectory [Nunney]

This inspection was carried out on 30th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Old Rectory [Nunney] 29/01/07

The Old Rectory [Nunney] 13/07/06

The Old Rectory [Nunney] 15/02/06

The Old Rectory [Nunney] 07/06/05

The Old Rectory [Nunney] 27/01/05

The Old Rectory [Nunney] 27/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Old Rectory High Street Nunney Frome Somerset BA11 4LZ Lead Inspector Sally Murphy Unannounced Inspection 11:15 30th July 2007 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 The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address High Street Nunney Frome Somerset BA11 4LZ 01373 836747 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 RONALD HILL MRS MARIAN CONSTANCE HILL MR RONALD HILL Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2007 Brief Description of the Service: The Old Rectory is a large detached property located in the village of Nunney, approximately four miles from Frome. Service user accommodation is provided over two floors. There is a passenger lift, assisted bathrooms, and a call system available. The Old Rectory is registered with the Commission for Social Care Inspection to provide care for up to 24 service users over the age of 65 years. The proprietors are Mr and Mrs Hill. Mr Hill is also the Registered Manager. The home has been decorated and furnished to a high standard. The garden has been well maintained and is accessible to service users. The fees are £373 - £418 per week, with additional charges for hairdressing, private chiropody and toiletries. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was carried out by Sally Murphy, and Shelagh Laver, Regulation Inspectors over one day. Since the last key inspection, random inspections have been completed on 7rh March 2007, and 3rd May 2007 by Regulation Inspectors, and Brian Brown, Regional Lead Pharmacist for CSCI, completed an additional inspection on 9th March 2007. Prior to the inspection the Registered Manager completed and returned information to CSCI regarding the service provided. The Registered Manager was available throughout this inspection. There were 16 service users residing at the home. During the course of this inspection, the Inspectors conducted a tour of the premises, observed care practice and talked with the Registered Manager, staff and service users. A number of care records including care plans, staff files and health and safety records were also examined. The Inspectors would like to thank the service users, staff and Registered Manager for their time and assistance during the inspection. What the service does well: The Old Rectory provides care to service users within a spacious and comfortable, family run home. There are adequate communal areas, and bathing facilities to meet service users needs. All service user rooms have en suite toilet facilities or sole use of a bathroom nearby. The home supports service users in accessing health care services. The home seeks specialist advice from GPs, District Nurses and Community Psychiatric nurses to enable them to fully meet service users needs. Service users spoke highly of the care and meals provided. Service users confirmed that they are treated with kindness and dignity. Whenever possible the home will support service users to stay at the home until the end of their life. The home will support service users during this period, working in partnership with the District Nursing team. Meals are prepared on the premises. Catering staff demonstrated a good knowledge of service users individual dietary needs and preferences. The home is maintained to a good standard of cleanliness. There were no malodours within the home. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 6 There are sufficient staff on duty to meet service users needs. Interaction between staff and service users was observed to be friendly and respectful. What has improved since the last inspection? What they could do better: The home should on complete pressure and nutritional risk assessments for each service user on admission to the home, and thereafter at regular intervals. The home should seek to increase the involvement of service users in developing and reviewing their plans of care. The management of medication is generally safe, although some aspects require improvement to ensure that procedures follow best practice. This is with regard to the recording of hand written entries on medication records, ‘as required’ medication and the administration of controlled drugs. The home should seek to further develop social activities to meet the individual needs of service users. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 7 The home must establish a system for ensuring that denture cleaning pots, grab rails, and other items such as plastic jugs are kept clean and hygienic, to reduce the risk of cross infection within the home. The home must develop a training plan to ensure that staff are provided with the appropriate skills and knowledge to undertake their role. This may include training on care planning, diabetes, infection control and abuse awareness. The home must ensure that a hoist is available, so that staff and service users are not put at risk of injury in the event of a service user suffering a fall, or requiring assistance to transfer. The home should consider undertaking a regular audit of accidents so that preventative measures may be taken. The Registered Manager must undertake regular audits at the home to ensure that improvements are sustained, as part of a Quality Assurance system. 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 DS0000016007.V343308.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5. (Standard 6 does not apply). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate information regarding the services and facilities offered at the home. A comprehensive assessment of need is obtained prior to a service user moving into the home. Service users had been provided with a written contract outlining the terms and conditions of their stay. EVIDENCE: The Old Rectory has a Statement of Purpose and Service User Guide that provide details of the services and facilities offered at the home. The The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 10 Registered Person must consider how copies of the inspection report may be made available to prospective and current service users within the home. One service user had recently been admitted to the home to receive respite care. An assessment of need had been completed. This service user receives regular respite care at the home. Service users confirmed that they had been invited to visit the home prior to admission to assess the facilities provided. At the random inspection completed on 27/3/07 service users confirmed that they had been provided with copies of a written contract outlining the terms and conditions of their stay. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide staff with sufficient information to appropriately assist service users in meeting their needs. Care plans evidenced that the home had requested appropriate input from GPs, District Nurses and Community Psychiatric Nurses to meet service users health needs. Further action must be taken to ensure that service users are consulted regarding the development and review of their plans of care. The management of medication is generally safe, although some aspects require improvement to ensure that procedures follow best practice. Service users confirmed that they are treated with dignity. EVIDENCE: The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 12 Care plans are maintained for each service user. Five care plans were examined in detail during this inspection. It was found that care plans provided details of service users needs and preferences. Appropriate plans of care had been developed to meet service users short term and long term needs. Specific care plans relating to diabetes and catheter care for individual service users had been further developed and found to contain necessary information. Care plans included information on the actions that service users could undertake independently and provided appropriate guidance to staff on the type and level of assistance needed. Service users had been weighed regularly. The records for one service user evidenced weight loss. The care plan showed the actions being taken to address this need. Service users had been provided with appropriate support to access health and social care services. Records had been maintained of the date, reason and outcome of professional visits. Care plans had been regularly reviewed. Those care plans seen included evidence of care plans being updated following a change in service users needs. Appropriate advice had been sought from health care professionals and risk assessments updated as needed. Risk assessments had been completed in relation to the use and storage of denture cleaning tablets. It was observed that footplates were in use on wheelchairs, and where this was not appropriate for one service user that a risk assessment had been completed and placed within their care plan. It was evident that staff had undertaken considerable work to review and develop care plans since the last key inspection. This was discussed during the inspection. Within the care plans seen some evidence of detailed care planning, review and re-assessment was seen. Staff must now further develop this area to consider pressure and nutritional risk assessments, and increasing the involvement of service users in developing and reviewing their plans of care. The recording, storage and management of medication was examined. Since the last key inspection the home has obtained a lockable trolley for the storage of medicine. This has provided a more secure system for the administration of medicine to service users throughout the home. Medication Administration Records (MARs) were examined. It was found that a record had been maintained of all medication entering and leaving the home. A signature had been recorded for all medication given. Staff must ensure that when a hand written entry is made on medication records that this is signed and dated. It is good practice for this to be checked and signed by a The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 13 second staff member to reduce the risk of error. When a medicine is prescribed on a ‘as required basis’, for example for pain, the reason for administration must be recorded so that staff know when that individual service user may require that medication. Medication requiring refrigeration had been stored securely and appropriate records maintained of the fridge temperature. Controlled drugs had been stored securely. The home must ensure that two signatures are recorded for the administration of a controlled drug. An opening date had been recorded for prescribed creams. Risk assessment had been completed in relation to the self-administration of medication. Service users spoke highly of the staff team. They confirmed that staff are kind and helpful, and that they are treated with dignity. Interaction between staff and service users was observed to be friendly and respectful. The home will provide care to service users until the end of their life whenever possible. At the random inspection on 3rd May 2007 the care plan was examined for one service user who had recently passed away at the home. This evidenced that the plans of care had been updated and reviewed as their needs had increased and regular contact with the District Nursing team. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are some activities available at the home. These should be further developed to meet service users individual needs. A choice of meals is provided. Meals are of a good standard and offer a balanced and nutritious menu. EVIDENCE: Service users advised that organised activities take place, with a musical entertainer and activities coordinator visiting the home each week. Since the last key inspection the home has sought the views of service users, and purchased music that they have expressed an interest in. Care plans included information on service users individual social needs and hobbies. The home plans to further develop the provision of social activities to ensure that it meets the individual needs of service users at the home. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 15 Service users are able to spend time within communal area, or their own room, as they prefer, and are able to access the garden. Visitors are welcomed at the home. A church service takes place within the home each month. Meals are prepared on the premises. Since the last key inspection the home has introduced a choice of menu at each mealtime. The Registered Manager has advised that the home has reviewed the menu to increase the range of meals provided. Service users spoken with were pleased with these changes, and spoke highly of the meals provided. Catering staff demonstrated a good knowledge of individual service users dietary needs and preferences. The home is able to cater for specialist diets. Lunch was observed. Music was playing in the dining room and the meal was served in a relaxed and unhurried manner. Service users were able to have their meal in the dining room or their bedroom as they prefer. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure. The home has appropriate policies and procedures in place to safeguard vulnerable adults. EVIDENCE: A copy of the home’s complaints procedure is displayed in the hallway. This includes the contact details of CSCI. There have been no complaints received by the home or CSCI since the last inspection. The home has an appropriate whistle blowing policy. For the protection of vulnerable adults the home has ensured that a POVA First check and two references have been received prior to a staff member commencing employment at the home. The home should obtain a copy of the updated Safeguarding Adults procedures from Somerset County Council. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 17 Those service users spoken with confirmed that they would feel able to raise any issues of concern, and knew whom they should speak with at the home. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live within a comfortable and homely environment. There are sufficient communal space and bathrooms to meet service users needs. The home is maintained to a good standard of cleanliness. Infection control procedures have improved, however these must be further developed to ensure that these address all areas of practice. EVIDENCE: Service user accommodation is provided on the ground and first floor. All service user rooms have en suite facilities, or sole use of a bathroom nearby. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 19 There are two assisted bathrooms, a passenger lift and call system available to service users. Communal space comprises of a large lounge, large dining room, and quiet room. Service user rooms have been personalised to reflect individual tastes and preferences. The home has been decorated and furnished to a good standard. Radiator guards have now been fitted in all parts of the home, and window openings restricted on the first floor. Hot water outlet temperatures were tested and found to be within appropriate limits. The home has emergency lighting fitted that is tested on a monthly basis. Since the last inspection the carpet has been replaced with main lounge. The Registered Manager is seeking to replace the armchairs within the lounges as part of the refurbishment programme for the home. During a tour of the premises it was noted that electrical wiring was accessible and needs boxing in near room 10 on the first floor. There is also water ingress on the ceiling in this area, which requires repair. The carpet on the first floor landing has started to ridge and must be regularly reviewed to ensure that it does not pose a trip hazard to staff and service users at the home. The home is generally maintained to a good standard of cleanliness. Some denture storage pots seen within service users rooms required thorough cleaning. This requirement has been outstanding since the last key inspection. Hand washing facilities consisting of liquid soap and paper towels and foot operated flip top bins have been provided for staff in all bathrooms, toilets, bedrooms where staff assist service users with personal care and the laundry. The laundry was found to be clean and hygienic. The home has improved infection control procedures and staff responded appropriately when there was an outbreak of sickness and diarrhoea at the home earlier this year. During a tour of the premises it was noted that the wooden base underneath the toilet close to the first floor bathroom was stained and requires thorough cleaning, and that the grab rails surround the toilet in the bathroom, and in one service user’s room have become rusty and require replacement. Staff must also ensure that bath panels and plastic jugs within bathrooms are kept clean to reduce the risk of cross infection within the home. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty to meet service users needs. The home has operated a robust recruitment procedure. Staff have been provided with updates in mandatory training. The home must develop a training plan to address further training and development needs. EVIDENCE: Duty rotas are maintained. There are generally two care staff on duty during the day, one domestic assistant and a cook. There is one waking member of staff on duty at night, with the Registered Manager being on-call if required. Staff and service users spoken with confirmed that staffing levels were appropriate to meet the needs of their needs. 16 staff are employed. These include 4 full-time carers, 9 part-time carers, and three catering and domestic staff. At present one member of staff has The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 21 completed NVQ level 2. There are four staff studying for this, and a further member of staff studying for the Level 3 qualification. Since the last inspection two staff have been recruited. It was found that two references and a POVA First check had been obtained prior to them commencing employment at the home. Both recruitment files were found to contain all required documentation. Since the last inspection staff have received updated training in moving and handling, and first aid. Newly employed staff had been provided with Induction training. It is recommended that the home utilise the Common Induction Standards provided by Skills for Care. The home must develop a training plan to address further training needs. The Registered Manager advised that supervision and staff appraisals were to be implemented. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for managing care provision have improved since the last inspection. The Registered Manager should undertake regular reviews of practice to ensure that improvements are sustained. Fire safety records had been appropriately maintained. The home must ensure that a hoist is available, so that staff and service users are not put at risk of injury in the event of a service user suffering a fall, or requiring assistance to transfer. Generally appropriate steps have been taken to promote the health and safety of service users at the home. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Manager and Provider is Mr Ronald Hill. Mr Hill has been the manager of the home for many years. He is assisted in the running of the home by his daughter who studying for the NVQ Level 3 qualification and is a senior carer at the home. At the last key inspection a number of areas were identified for improvement. The Registered Manager and staff at the home have worked to address many of these. The Registered Manager must now consider systems for monitoring and reviewing practice to ensure that improvements are sustained. The home does not have any formal systems for obtaining feedback from service users on the service provided. Service users stated that they would feel able to raise any issues of concern. The home will keep money securely for any service users that wish them to. Records are maintained of all transactions involving service users finances. Monies were checked for three service users and found to tally with records kept. The home displays appropriate Employers Liability insurance. Records relating to service users are stored securely and kept up to date. Fire safety records were examined. It was found that fire safety equipment had been tested and serviced as required. Staff had been provided with updates in fire safety training. Since the last key inspection, the Registered Manager has completed the fire risk assessment. Dorguards that are linked to the fire detection system have been fitted to some doors within the home. Servicing records relating to portable appliances, the passenger lift, and bath hoists had been appropriately maintained. The hoist requires repair. The Registered Manager must ensure that this is replaced or repaired as a priority. Kitchen cleaning and temperature records had been appropriately maintained. Cleaning fluids including bleach were left unattended whilst staff were vacuuming within a nearby bedroom. The home must ensure that hazardous substances are not available to vulnerable service users. The rails in use in one service users bed may pose a risk of entrapment. This was discussed during the inspection. The Registered Manager agreed to determine whether these were still required to assist the service user out of bed, and to ensure that they were fitted in a manner that reduced any potential risk of injury to the service user. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 24 Accident records completed appropriately. The home should consider undertaking a regular audit of accidents so that preventative measure may be taken. The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 3 3 2 The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement The registered person shall consult service users in the development and review of their care plans. Timescale for action 10/10/07 2. OP9 13(2) The registered person shall make 16/08/07 arrangements for the recording, safekeeping and safe administration of medicines in the care home. This relates to the need to ensure that:When medication is prescribed on an ‘as required’ basis, guidance must be provided to staff of the condition or symptoms that this is to treat. (Previous timescale of 18/06/07 not met). All hand transcribed entries must include the quantity of medication, date and staff signature. 3. OP12 16 (2n) The registered person must ensure that social needs plans are developed so that activities are provided to meet service DS0000016007.V343308.R01.S.doc 01/10/07 The Old Rectory Version 5.2 Page 27 users individual needs and interests. (Previous timescale of 31/03/07 not met). 4. OP19 13 (4a) Electrical wiring is accessible and needs boxing in near room 10. Repairs must be made to the ceiling near room 10 (on the first floor) that has suffered water damage. (Previous timescale of 09/03/07 not met). 5. OP26 16 (2j) Denture cleaning pots must be kept clean and hygienic. (Previous timescale of 23/02/07 not met). The wooden base underneath the toilet close to the first floor bathroom was stained and requires thorough cleaning. The grab rails surround the toilet in the bathroom, and in one service users have become rusty and require replacement. Staff must also ensure that bath panels and plastic jugs within bathrooms are kept clean to reduce the risk of cross infection within the home. 6. OP30 18 (1c) Staff must be provided with the appropriate training for the work that they perform. This will include training on: care planning, medication, diabetes, infection control, and abuse awareness. The registered person must The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 28 01/10/07 10/09/07 31/08/07 submit a training plan with appropriate timescales by 31/3/07. 7. OP31 24 (1) The Registered Manager shall establish and maintain a system for reviewing and improving the quality of care provided at the home. The home must ensure that a hoist is available, so that staff and service users are not put at risk of injury in the event of a service user suffering a fall, or requiring assistance to transfer. Accidents must be regularly audited to ensure that preventative measures may be taken. (Previous timescale of 09/03/07 not met). 01/10/07 8. OP38 13 (5) 10/09/07 9. OP38 17 (1) 10/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 Good Practice Recommendations It is recommended that a pressure risk and nutritional risk assessment is completed for each service user on admission to the home, and reviewed on a regular basis. It is recommended that hand written entries on medication record are checked and signed by a second staff member to reduce the risk of error. All records relating to Controlled Drugs should include two staff signatures. 2. OP9 The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 29 3. OP28 The home must continue to support and encourage staff in obtaining this qualification. The National Minimum Standards for Older People state that at least 50 of the care staff employed should have completed this qualification. It is recommended that the home utilise the Common Induction Standards provided by Skills for Care. The home should consider establishing quality assurance systems such as residents meetings or service user surveys to seek feedback on the service provided. Staff should receive supervision at last six times each year. 4. 5. OP30 OP33 6. OP36 The Old Rectory DS0000016007.V343308.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 DS0000016007.V343308.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!