Inspection on 05/10/05 for The Old Rectory (Trowbridge)

This inspection was carried out on 5th October 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Rectory (Trowbridge) 04/01/10

The Old Rectory (Trowbridge) 12/09/07

The Old Rectory (Trowbridge) 29/06/06

The Old Rectory (Trowbridge) 06/05/05

The Old Rectory (Trowbridge) 24/09/04

The Old Rectory (Trowbridge) 28/05/04

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 Old Rectory (The) 27 Stallard Street Trowbridge Wiltshire BA14 9AA Lead Inspector Tim Goadby Unannounced Inspection 5th October 2005 09:50 Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Old Rectory (The) Address 27 Stallard Street Trowbridge Wiltshire BA14 9AA 01225 777728 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) Parkcare Homes (No. 2) Limited Mr Ean Rayton True Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th May 2005 Brief Description of the Service: The Old Rectory provides care and accommodation for up to 8 adults with a learning disability. There is a particular focus on autism. The home is operated by a subsidiary of Craegmoor Healthcare, a private sector organisation with 4 registered care homes for this client group within Wiltshire. The property is situated in a residential area of Trowbridge. A range of amenities are available in the town itself. Larger centres, such as Bath and Bristol, are within reasonable travelling distance. The service has been in operation for almost 10 years, initially under different ownership. A number of service users have lived there from the beginning. The current group is well established. They are all males. All service users have single bedrooms. This includes some on the ground floor. 2 bedrooms have en-suite facilities. The others have bathrooms and toilets nearby. Communal areas are situated on the ground floor. There is access to a large enclosed garden. There is also an adjacent building, which is used for daytime activities. Another plot is used to grow vegetables. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in October 2005. A total of 4.5 hours were spent in the home. The following inspection methods have been used in the production of this report: indirect observation; pre-inspection questionnaire, completed by the provider; sampling of records, with case tracking; sampling a meal; discussions with service users, visitors, staff and management; survey of service users, relatives and professionals; tour of the premises. Some immediate requirements were set at the conclusion of the inspection. These were then confirmed in writing to the home. Some information relating to progress on these has been supplied to the CSCI subsequently, and is incorporated into this report. What the service does well: What has improved since the last inspection? Existing and prospective service users now have all the necessary information about the home. The Statement of Purpose has been updated, to ensure that it contains all correct current details. Individual service users’ information also now includes completed statements of terms and conditions of residence, which they have signed. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 6 The kitchen has been completely refitted, and is now a much improved facility. Both service users and staff benefit from this. A new approach to induction and foundation training has been implemented across the organisation. This links to national occupational standards for the social care workforce, and to those particularly developed for staff working with people with learning disability. New staff are also assigned a ‘supportive colleague’ to work alongside during the initial stages of their employment. This approach helps to ensure that new starters speedily begin to develop the knowledge and skills needed to support service users effectively. There is better evidence that service users are protected from any fire safety risks. Deficits in the recording of checks and instruction have been addressed. No omissions were found on this occasion. Craegmoor has appointed a national head of autism services to lead the group’s approach in support to this service user group. Various changes are expected to flow from this, including a complete revamping of the approach to care planning. The home has also just acquired a new training package on positive approaches to supporting people with autism. It is anticipated that this will prove useful in identifying ways to work with the Old Rectory’s own service users. What they could do better: Documented evidence of suitable plans to improve the property has been an unmet requirement at the last two inspections. A major programme of investment is needed to address issues of maintenance and décor requiring attention throughout the property, both internally and externally. This is important, to ensure that service users’ quality of life is not impaired by the surroundings they inhabit. It was reported that funding has been allocated, and that the project should start shortly, with an anticipated completion date of September 2006. This process must be accompanied by a suitable action plan, which sets out priorities and timescales, and describes how the impact of such work on the continuing operation of the service will be managed. An immediate requirement was issued at the close of the inspection, requiring initial evidence of such a plan not later than 31st October 2005. Concerns were identified about the administration and recording of medication for service users. These chiefly related to the use of pain control drugs with one individual, which had been prescribed to be taken ‘as required’. Deficits in practice placed the individual at risk. Immediate requirements were issued in respect of the relevant issues, and the home took suitable steps to address these within a week of the inspection date. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 7 Some improvements in service user records could help to show more effectively how individuals are involved in planning their own care. Consideration should also be given to providing clearer information about risk management judgements and strategies. This will evidence that appropriate steps are in place to benefit service users. Staff records are well maintained, but care is needed to ensure that relevant information is updated where appropriate. This will provide all necessary evidence that the welfare of service users is being upheld. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 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 Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 Prospective service users have the necessary information to make a choice about the home. Service users have their needs and aspirations met by the home. Service users have individual terms and conditions of residence in the home. These have been produced in formats designed to be appropriate to them. Standards relating to admissions to the home were not applicable at this inspection. EVIDENCE: The Old Rectory has a Statement of Purpose, and Service User Guide. These are readily available. The Statement has been updated since the previous inspection, and now contains correct current information. The Guide has been produced in accessible formats. The home has not had any new admissions for over 2 years, so the current service user group is well established. Information is available to describe their needs, and the strategies to support these. Staff support is in place for all service users throughout the day. This enables them to be offered a variety Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 10 of opportunities. Records also show that a range of professionals and resources are accessed, to assist the home in meeting its service users’ needs. The Old Rectory’s particular focus is on supporting people with autism. Appropriate steps are taken to ensure that staff are given relevant knowledge and skills to support individuals with such complex needs. Craegmoor has also now appointed a national head of autism services to lead the group’s approach. Sampled files show that current terms and conditions of residence are included within each individual service user’s information. These have been signed by the people themselves. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Service users’ needs and goals are reflected in their individual care plans. Their own input to these could be developed further. Systems for risk management support the undertaking of social opportunities. The format used could be clarified, to provide better evidence of the approaches in place. EVIDENCE: The home’s current care plan format addresses all required areas. But the input of service users themselves is not a strong feature. The approach is due to be completely revamped, within an overall review of this area by Craegmoor. There will be a twin track system. A person centred plan, developed with the service user, will focus on their own goals and aspirations. Alongside this, there will be a more traditional care plan, which will set out the support that staff need to give to the individual. Risk assessments show consideration of positive reasons to take risks, as well as potential negative outcomes. Where possible, they place emphasis on the support that can be given to enable an opportunity to be undertaken. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 12 As at the previous inspection, however, some deficits were identified from the sample viewed. The format is not entirely clear. It is not always apparent whether the risk level judgement is made before or after putting relevant measures in place. The definition of a risk as low, medium or high does not appear to be linked to any objective criteria. Gradual progress is being made on this issue, as various documents are reviewed. A risk assessment for one service user concerns whether or not they could retain their own room key. This has not been amended since the previous inspection, when it was highlighted as an example. From the document alone, it is not possible to conclude what decision has been reached. The same assessment form has also been used to address a separate issue, regarding access to the kitchen. Linking these two topics has contributed to the confusion. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Service users have the opportunity to maintain and develop skills. Service users have frequent opportunities to undertake a range of activities, both at home, and within their local community. Service users are supported to maintain personal and family relationships. Daily lives for service users have an appropriate balance between necessary routine, and individual choice. Arrangements for the provision of meals promote independence, choice and social inclusion. EVIDENCE: The Old Rectory has an adjacent building which offers a range of daytime opportunities. Examples of the various activities undertaken by people are on display. Some service users also attend the local college, supported by staff Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 14 from the home. Courses undertaken include independent living, money management, and sport. Service users are regularly supported to get out and access a range of opportunities. Staffing levels support this. The home also has 2 vehicles. On the day of this inspection people undertook various activities. One person went to a local shop in the morning, and then caught the train into Bath with their keyworker. Others went out also. All service users had been away on holiday over the course of the summer, supported by staff. Residents had usually gone in pairs, although a couple of people went singly. Destinations included a trip to a theme park in France for one service user celebrating his 21st birthday. Records show that good links are maintained with service users’ families. Key information is shared, where appropriate. Visitors can come to the Old Rectory. Residents are also enabled to go and stay with family or friends. 5 relatives completed comment cards for the CSCI. These all gave positive feedback about the service provided by the home. All respondents felt that they are kept appropriately informed and consulted about the care of their relative. All but one service user have weekly timetables on display. These are produced in pictorial form, to promote understanding. They show that each individual has a range of planned activities to fill the week, both at home and elsewhere. There is also a daily shift plan to assist staff in achieving all necessary tasks. However, flexibility is built in, especially where needed to reflect an individual’s needs. Lunch on the day of the inspection was home made soup, with rolls. Fruit or yogurt was available for dessert. Staff and service users ate together, in a pleasant social atmosphere. The whole household did not dine at the same time, and some people were out for lunch. Support needed by one individual was given sensitively. Various service users assisted with relevant tasks, such as clearing tables. One resident is more independent, usually buying and preparing his own meals. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users are supported to address their personal and health care needs effectively. Service users are placed at risk by deficits in the home’s practices for the administration and recording of medicines. EVIDENCE: Service users’ personal care needs are set out in their individual plans. Abilities and needs vary widely amongst the group. Some are fairly independent, and need only advice or prompting from staff. Others are much more dependent, and require direct assistance with all relevant tasks. The level of support given is tailored appropriately, with guidance set out in records. Service users have various health needs, and records show that appropriate steps are taken to respond to these. People are supported to access input from relevant professionals. No service users are self medicating, so staff take on the responsibility for storage, administration and recording of medication. Arrangements for Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 16 storage are appropriate and secure. Administration is carried out by a senior carer, with another staff member witnessing. All care staff receive training in medication, via the pharmacy which supplies the home. The medication protocol is also used as part of the in-house training programme. Staff sign to indicate that they have read this, and will abide by it. The medication folder contains a section on each service user. This includes their administration record chart; a care plan on how they take medication; information about any reviews or changes of prescription; and individual guidelines for any drug which is prescribed to be taken ‘as required’. Some deficits were identified in medication practice, which led to the issuing of immediate requirements. These were to do with the use of ‘as required’ pain control medication for one individual. Records indicated that the person had been given 2 drugs, both containing Paracetamol, simultaneously. This would be in contravention of safe practice, as set out on the medication packaging, and highlighted in his own records. The manager’s enquiries, when this was pointed out, indicated that this was a recording error, rather than one of administration. The correct practice in such circumstances therefore needed reinforcing to staff. The service user’s safety was compromised by both drugs being written up to be given ‘as required’ on his current medication sheet. Guidance was only in place for one of them, and was not dated. Records also showed that one of the drugs, although prescribed ‘as required’, was routinely being given once a day. It was therefore recommended that the prescribing doctor should be consulted again, to check that this remained in line with their intentions. Requirements were confirmed in writing after the inspection, with a deadline for compliance of 12th October 2005. The manager supplied relevant information by that date, demonstrating that appropriate steps had been taken to address all identified issues. This was checked by the CSCI’s pharmacist inspector, and deemed to be suitable. The service user has attended a GP appointment for review of their prescription. One medication has been stopped, and the dose for the other has been altered. The manager has also amended relevant individual and general policies. A senior team meeting is to be held to agree the changes, and the information will then be cascaded throughout the staff team. On the inspection date, another service user had two sets of guidance for the same ‘as required’ medication. These differed slightly. As neither document was dated, it was not possible to judge which was the correct current advice. Such duplication and confusion should be avoided, to minimise the likelihood of Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 17 any errors occurring. Guidance also failed to show that it was being kept under review. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: The complaints procedure is prominently displayed within a public area of the home. Recording systems are in place. The Old Rectory has also made referrals to local vulnerable adults procedures, when required. A service user’s file was sampled, and showed that this process had assisted in identifying actions to put in place to minimise the risk of the individual coming to any harm. Some service users have complex and challenging needs. These can include issues arising from personal relationships. Relevant professionals are involved in giving support to these individuals, and in supporting the home to develop suitable approaches for management of difficult situations. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 Significant improvements are required to the quality of the living environment for service users. EVIDENCE: Previous inspections have highlighted the need for significant improvements to the fabric of the building. It is recognised and acknowledged by Craegmoor as an issue requiring major investment. A large scale programme of works has now been authorised, and funds allocated. The whole property is to be refurbished, with a timescale for completion of September 2006. A project manager is to be appointed to oversee this. No documented action plan was available as yet. This meant that a requirement from the 2 previous inspections remained unmet. The issue was discussed during the inspection with the registered manager, and by telephone with Craegmoor’s area manager. The organisation accepts that the current position is not acceptable, and provided assurances of their intentions to remedy this. It was agreed that an initial action plan would be supplied to the CSCI not later than 31st October 2005. This is to confirm works to be undertaken; the Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 20 budget for the scheme; and the expected completion date. The plan can then be reviewed and updated appropriately, as more details became available. Each service user has a single bedroom. One person has an individual flat, with separate access internally. He took pleasure in showing this, and clearly appreciates the space available. This resident, and one other, have keys to their own rooms. 7 bedrooms were seen during this visit, with the permission of their occupants. They are furnished and decorated to reflect the personal taste of the service user. For instance, one is provided with sensory equipment, which the individual enjoys using. Some rooms have been redecorated over recent months, including those with en-suite facilities. There are two lounges on the ground floor. The smaller of these tends to get little use at present, so the home is trying to identify different ways of promoting this. The kitchen has been completely refitted since the previous inspection, giving service users and staff much improved facilities in this area. The home appeared clean and hygienic to a reasonable standard in all areas seen. A cleaner was on duty in the morning, and was observed carrying out deep cleaning of one bedroom. Service users and other staff also take part in relevant tasks. Some parts of the home are difficult to keep clean, due to the need for refurbishment. The garden is well maintained, and attractively landscaped. A number of overgrown trees and bushes have been pruned or removed since the previous inspection. Bamboo screening is now being fitted around the perimeter fence, to provide greater privacy. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 & 35 Service users are supported by suitable numbers of appropriately trained staff. Service users are protected by effective recruitment practices. EVIDENCE: The home was suitably staffed on the day of the inspection, and rotas provided evidence that cover is maintained at high levels of staff to service users. There are a minimum of 4 staff on duty during daytime hours, if all residents are at home. The usual aim is to have 6 staff on a morning shift; and 5 in the afternoon and evening, up until 22.00. Some residents need one-to-one support for much of the time. This responsibility is shared amongst the staff on duty. Night time cover consists of 1 waking and 1 sleeping member of staff. There is a separate team of waking night staff, although other carers may also occasionally cover these shifts. There has been a period of staff turnover in recent months. Absences of other employees have also led to pressure on rotas. Cover has been maintained Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 22 from within the organisation, avoiding any use of agency staff. Recruitment has now taken place, and the various necessary checks were being concluded. 2 staff files were sampled, of people who have been appointed since the previous inspection. These records demonstrate that all required recruitment checks have been carried out at the appropriate times. The process is administered centrally, from Craegmoor’s head office. A checklist is in place of the various stages required. Records show that a range of relevant courses are provided to staff, from induction onwards. Craegmoor has its own training department. External providers are also accessed as necessary. A new approach to induction and foundation training has just been implemented across the organisation. This links to national occupational standards for the social care workforce, and to those particularly developed for staff working with people with learning disability. Successful completion of this package also provides workers with a pathway into NVQ training. New staff are assigned a ‘supportive colleague’ who will shadow and assist them during the early stages of their employment. The home has also just purchased a training package on approaches to supporting people with autism, developed by a national organisation providing such resources to the learning disability field. Senior staff are due to work through this initially. It will then be used as an aid to training for the whole team. The benefit of such a package is that it can be tailored directly to the needs of the service users supported by the Old Rectory. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 41 & 42 Service users benefit from a well run home, which receives good organisational support. Effective record keeping is maintained, upholding service users’ best interests. Service users are protected from risk of fire by the safety systems in place. EVIDENCE: The home’s registered manager is Mr Ean True. He has worked at the Old Rectory for a number of years, and was previously the deputy manager. He has obtained his Level 4 NVQ in management, and is now enrolled for the Registered Manager Award. Records are stored securely. Clear guidance is in place about confidentiality, and the boundaries around sharing of information. Sampled service user records showed that entries are made 4 times a day, including for the Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 24 overnight period. There is a clear division between objective and subjective comments. This provides a detailed ongoing record of care. Care is needed to ensure that any relevant documentation is updated where appropriate. For instance, in one of the sampled staff files, an employee’s residence permit was valid at the time of their appointment, but has since expired. There is no evidence that this has been renewed. The manager reported that the organisation’s human resources department are chasing this matter up. The fire log book was viewed. All checks and instructions relating to fire safety were seen to be recorded as being carried out, and up to date. Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 N/A 3 N/A 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Old Rectory (The) Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X 3 3 X DS0000028608.V255942.R01.S.doc Version 5.0 Page 26 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 YA20 Regulation 23-2b Requirement The persons registered must produce a maintenance plan for the building. (Timescale of 31/01/05 not met) Timescale for action 31/10/05 2 YA20 12-1;13-2 COMMENT: No documented action plan was available. A final short notice timescale was set during the inspection. The persons registered must 12/10/05 ensure that there are suitable arrangements for the recording and administration of all medication given to service users. COMMENT: This was issued as an immediate requirement, and has been met since the inspection date. This part of Regulations also applies to the above Requirement. There must be clear guidance on the criteria for administration of medication prescribed on an ‘as required’ basis. COMMENT: This was issued as an immediate requirement, and 2 3 YA20 YA24 17-1a,Sch 3-3m 12-1;13-2 12/10/05 12/10/05 Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 27 3 YA20 17-1a,Sch 3-3m has been met since the inspection date. This part of Regulations also applies to the above Requirement. 12/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA9 Good Practice Recommendations Care plan formats should be reviewed to show the input of service users. The home’s risk assessment format should be reviewed and clarified. COMMENT: Progress was being made on this recommendation. All guidelines for ‘as required’ medication should be clearly dated, and any duplication should be avoided. COMMENT: This recommendation has been addressed since the inspection date. All records relating to staff should be kept updated. 3 YA20 4 . YA41 Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Old Rectory (The) DS0000028608.V255942.R01.S.doc Version 5.0 Page 29 - 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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