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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

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Enforcement action taken

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

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

The provider did not have an effective system to regularly assess and monitor the quality of service that people receive.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

Reasons for our judgement

People who use the service and others who may be affected were not consistently protected from risk.

We found that the service had not assessed the risks to people of falls from windows, balconies or fire escapes. The provider had booked a contractor to complete some remedial work following a recent incident at the service. Environmental risks were evident at the service including an accessible pond. This, and other risks had not been assessed and an environmental risk assessment had not been completed. We could not be assured that all potential risks had been identified and action had been taken to put adequate arrangements in place to protect people.

The service had a current fire risk assessment in place. On the first day of our inspection fire maintenance contractors attended the service to complete scheduled checks on fire safety equipment such as smoke detectors and the alarm system. The local fire and rescue service had visited the service recently following a referral we made. The fire service had found blocked fire escape routes and locked fire exits as well as a lack of personal evacuation plans. The fire service advised that the fire risk assessment and fire safety procedures required improvement to ensure that all risks were identified and managed to keep people as safe as possible.

Following advice from the local authority the service had put a process in place to assess and manage the risks posed to people using the service from visiting contractors, such as decorators. We found that no contractors had visited the service since the introduction of the process, therefore we were unable to assess if the new process was effective.

There was no evidence that learning from incidents / investigations took place and appropriate changes were implemented. Staff told us that they noted when people had accidents, such as falls, and contacted the person’s doctor. We found evidence that the service had responded appropriately to high risk incidents. The service did not have process in place to analysis and take action to learn from incidents and accidents that took place. This meant that appropriate changes could not be made to keep people safe.

The provider did not operate an effective system to regularly assess and monitor the quality of the service provided. Weekly housekeeping audits and monthly checks on medicines were carried out. However, no further checks and audits on the quality of the service were completed. This meant that the provider did not have adequate systems in place to regularly assess and monitor that the quality of the services so people could not be assured that their health, safety and welfare would be protected.

People who used the service, their representatives and staff were not regularly asked for their views about their care and treatment. There was a process in place to do this but this had not been completed since 2011. We saw that people and their relatives spoke to staff about the service they received on an informal basis but we could not be assured that the provider had robust processes in place to regularly ask people and their representatives for their views and act upon the feedback received to reduce the risks of people receiving inappropriate or unsafe care.

The service does not hold regular staff meetings. The last recorded meeting was October 2013. Staff had provided feedback at this meeting to the provider about areas of the service which required improvement, such as laundry equipment. We saw that the Head of Care held meetings with small groups of staff at the beginning of each shift. Staff had received information and guidance about areas that required improvement such as the wording of people’s records and staff behaviour whilst on duty at these meetings. So, areas where the quality of the service did not meet the standards expected had been identified and action had been taken. However, the service did not have a formal, current process in place ask staff for their vi