The Old Rectory Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty.

Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Accidents and incidents were recorded and analysed to ensure future risks were mitigated. Learning was documented and shared during handovers, so staff had the information to support people safely. Staff shared their commitment to learn from incidents. One staff member told us, “We talk about things that happen with the manager and talk about if we can do anything in a different way.” The registered manager understood their responsibility to be open and honest with people when errors or omissions had occurred.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager confirmed that people had an ‘index sheet’ that was used if they required medical treatment outside of the home. This contained a summary of important information and outlined the person’s care needs. The registered manager told us they keep in regular contact with the hospital when a person is admitted.

Staff and the registered manager worked closely with health and social care professionals to ensure people had access to joined up care. One staff member told us, “The GP comes every week. We update the manager about any resident who’s not feeling well or if say, the antibiotics they have are not working.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA) and how they managed Deprivation of Liberty Safeguards (DoLS). People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. The registered manager had not submitted a DoLS application for any residents living in the home even though staff told us some people would not be free to leave should they wish to do so, for their own safety. There was a risk that people would be subjected to restrictions without the legal framework in place to support their safety. The manager agreed to undertake additional learning on this topic and confirmed the appropriate DoLS applications would be submitted.

People and relatives shared that the home was a safe place to live. One person living at the service commented “I feel safe, I would tell [family member] if I didn’t feel safe.” whilst another person stated, “I feel safe here… even at night.” One relative told us, “I think that mum is safe, she has dementia, and they look after her well.”

Staff received safeguarding training and understood how to protect people from abuse. One staff member told us, “From my training I learnt about all the different types of abuse… If I saw something worrying, I would go straight to the manager and report it.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care records showed people had assessments to manage individual risks. However, risk assessments did not identify all potential hazards and there were insufficient control measures to effectively mitigate the risks identified. For example, a risk assessment for paraffin-based creams lacked detail putting people, staff, and others at risk of harm as these products are highly flammable and can increase fire risk. Following our feedback, we found improvements to this risk assessment had been made on our second visit.

Staff understood how to manage risk. One staff member told us, “If you think there is a risk, perhaps a resident seems unsteady, you would report it straight away and the manager would do or review the risk assessment even out of hours.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Checks had failed to identify fire safety concerns in the environment. For example, a fire door was held open with a wooden wedge. This meant the door would not close in the event of the fire when the fire alarm was activated and therefore would not provide any level of protection. Some ceiling tiles had been displaced, we observed a hole in the ceiling of one room as well as in the door of another room. This further added to the risk of fire spreading.

Chemicals were not stored securely, with some left out in a communal area and a bottle of toilet cleaner in an unlocked cabinet.

There were several issues with storage. The bathroom was overfilled with equipment such as bed frames and walking aids. The manager told us there were currently no residents who wanted to have a bath, but said if they did, staff would move everything. Additionally, the shower room was also used to store equipment. Residents regularly used the shower room, meaning staff had to move equipment out of the room to accommodate this.

The registered manager accepted our feedback and took immediate action to address these issues. For example, fire risks were mitigated, and the bathroom and shower room were decluttered.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff had been recruited safely in line with the providers recruitment processes. This ensured checks had been completed prior to staff starting work at the home to ensure their suitability. Records confirmed staff had completed an induction, training and had regular supervisions

People received staff support when they needed it and told us there was enough staff, including at night and at weekends. Throughout our inspection we saw staff were available to respond to people’s needs. Staff had no concerns about staffing levels. One staff member told us, “We have enough staff. We have time to sit with the residents which is very important.” The registered manager described how staffing levels were flexed to meet people’s needs and where appropriate occupancy levels.

Staffing rotas demonstrated staffing levels were maintained and people were supported by a consistent staff team. One staff member explained staff were willing to provide cover for planned and unplanned absence. They said, “Consistency for our residents is a priority.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Whilst staff had completed infection, prevention and control (IPC) training, some staff did not follow good IPC practice in line with the provider’s policy. For example, some staff were observed providing care and support whilst wearing jewellery and acrylic nails. In the laundry, a red soluble bag, used to isolate soiled laundry, was not separated from other items waiting to be washed. Toilet rolls had been left on top of a sanitary unit in the visitors’ toilet and cleaning schedules in communal toilets contained significant gaps. These practices increased the potential risk of cross contamination.

The provider’s monthly checks to monitor infection prevention and control measures within the home were not always effective. The latest audit dated 30 September 2025 had not identified the issues we found.

However, staff had access to personal protective equipment (PPE). One staff member commented, “There is always a good stock of gloves, aprons and masks.” Staff were observed wearing and disposing of used PPE safety. The provider’s infection prevention and control policy had been reviewed in in June 2025 and reflected current best practice.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Some medicines, including controlled drugs (CD’s), were not securely and safely stored in line with National Institute for Health and Care Excellence (NICE) guidelines or the providers own policy and procedure. We observed prescribed creams and lotions in plastic baskets and the locked metal cupboard containing CD’s in the home’s food pantry. The door to the food pantry was unlocked and access to the room was not controlled. Manufacturer’s instruction for some creams and lotions specified they must not be stored at a temperature above 25 degrees Celsius. This is important as storing creams and lotions above the recommended temperature can make them less effective. The room had no means of controlling the temperature and staff confirmed the temperature of the food pantry was not monitored.

Records indicated some people had not received their medicines as prescribed. This was because the physical stocks of 3 people’s medicine did not add up with the amount recorded as received and administered.

One person’s prescribed controlled drug had been discontinued by the GP. The CD register had not been updated following this change, creating the risk that a discontinued medicine could be administered.

People expressed satisfaction with how their medication was managed. For example, one person told us, “They never forget to give me my medication,” while another said that staff ensure they take it as prescribed.

People’s medicines were ordered and safely disposed of in line with the provider’s policy and procedure.

The registered manager had taken action to address our concerns. We found improvements in the management of medicines on day 2 of our inspection.