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Archived: The Old Rectory Inadequate

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Inspection report

Date of Inspection: 26, 27 June 2014
Date of Publication: 9 August 2014
Inspection Report published 09 August 2014 PDF

People should be protected from abuse and staff should respect their human rights (outcome 7)

Not met this standard

We checked that people who use this service

  • Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 26 June 2014 and 27 June 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and reviewed information sent to us by other authorities. We talked with other authorities.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

People who use the service were not always protected from the risk of abuse because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening where a person may not have capacity.

Reasons for our judgement

Since our previous inspection the service had taken action to put suitable arrangements in place to ensure that people were protected against the risk of abuse.

At our last inspection we found that the provider had stopped staff members working at the service when the local authority safeguarding team had received safeguarding allegations which implicated individual staff members. During this inspection we found that staff had only returned to work following an investigation by the local authority safeguarding team. The provider had also completed their own investigation and met with the person prior to their return to work to address any concerns. For example, we saw that additional supervision and training had been put in place for one staff member. This meant that the provider had taken action to make sure safeguards were in place when a staff's practice had been questioned.

A few of the people using the service were involved in sexual behaviours or physical relationships. During our previous inspection we were concerned that no regard, by way of assessment, had been given to people’s capacity to consent. During this inspection we saw evidence to demonstrate that the service had supported people, who had capacity, to work with health professionals around certain behaviours, to keep themselves and others safe. We also found that the service had worked with health professionals to understand if one person was happy with the affections another person was showing them. The provider had not taken action to assess, where a person may not have capacity, that they understood the consequences of their behaviour and were making an informed decision.

People using the service we spoke with told us that they felt safe and that staff supported them when they needed. People showed us how they kept their personal items safe. We also found that where people wanted to they held a key to their room and were able to lock their door. Appropriate arrangements were in place to enable staff to access people’s rooms in an emergency.

Some people’s care plans showed that there was a risk that they may take other people’s things. We found that staff were aware of these risks and strategies were in place to support people to understand why they should not do this. We saw evidence that staff had supported people to return items to their rightful owner.

Some people had gates across their bedroom doorway to prevent other people from entering their rooms. We observed that people were happy for these gates to be in place and that they did not stop the person from leaving their room. People’s care plans recorded why they gates were in place, for example, to prevent people walking in and taking the person’s things. This meant that arrangements were in place to safeguard people’s personal items.

When one person had informed staff of concerns they had, staff followed the services safeguarding policy to inform the person’s care manager in a timely way. The deputy manager and the head of care for the service told us that they had met with the local authority safeguarding co-ordinator recently as the safeguarding coordinator wanted to go through safeguarding protocols. They both described how they would raise alerts from now on. This meant that the service had changed their safeguarding process to include information given to them by the local authority.

At our previous inspection we found that there was a risk that people were not protected against the risks of unlawful or excessive control or restraint because the provider had not made suitable arrangements to protect people. Since then, the service have informed us that all of the bedrails and lap straps used by people were assessed and provided by health care professionals and they have completed bedrail assessments for people where they were in use. They had also taken some assessments and other documents out of their archives to show why bedrails and laps straps were in use. As these had