The Old Rectory

The Old Rectory is a residential care home providing personal care to 8 people with autism and learning disabilities at the time of the inspection.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to eight people. Eight people were using the service. This is larger than current best practice guidance of six. However, the size of the service was not having a negative impact on people and was mitigated by the size of the home and building design fitting into the residential area.

The service was developed and designed in line with most principles and values that underpin Registering the Right Support and other best practice guidance. This guidance ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service and what we found

The management of the service did not have a consistent oversight of how staff spent their time or if there were shortfalls in staffing. We received conflicting feedback from the registered manager and staff about why some people were missing out on opportunities to access the community. Reviews indicated these were long-standing issues and that some people were not prioritised over others because their needs were more demanding of staff time.

Medicines were not consistently managed safely. Some areas for improvement were identified in the leadership audits, but we found other shortfalls which had not been identified.

The registered manager recognised there were areas for improvement in the quality monitoring of the service. Also, in documenting how people were being supported to achieve positive outcomes.

Most areas of the home were clean and tidy, although there were some areas which would benefit from redecoration. This was partly due to the age of the building and continual maintenance was planned. One person’s bedroom had a strong odour, due to water on their carpet. Plans to address this were only considered when we raised concerns about the smell.

People had personalised support plans in place. These reflected people’s usual routines, what was important to them and what staff needed to know to support them.

People’s involvement in decisions about their care was promoted. Some people used advocacy services. Others were independent in making decisions and some people had involvement from their family members.

There was a range of different meals and drinks available for people. We saw people choosing different lunchtime meal options. People who could make their own food were encouraged to do so.

Staff received training in a range of different areas, including equality and diversity. People’s cultural identity needs were respected and supported.

People’s privacy was respected. People had access to different communal rooms to spend their time, as well as a large garden. There was also a hall which could be used for events and activities.

The home was in a good location for community access by foot or public transport. The registered manager had developed good relationships with the local resident’s group. People from the community were invited into the garden for annual garden parties.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 8 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Old Rectory on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to the leadership of the service and managerial oversight of how staff support people at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Old Rectory provides care and support for up to eight people with a learning disability, autistic spectrum disorder. At the time of our visit seven people were living at the home.

There was a registered manager in post. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

People were supported to make day to day decisions. We saw people make decisions about activities and meals. Where people lacked capacity to make specific decisions, best interest decisions were taken. The registered manager had improved the information included within best interest action plans however the best interest decisions reached were not always reviewed to ensure the decisions remained accurate. Actions plans did not provide an audit trail of the actions which included applications to Deprivation of Liberty Safeguards (DoLS) where restrictions were to be imposed.

Care records included people’s life stories and care plans detailed people’s preferences on how their care and treatment were to be delivered. We found care plans were duplicated and when people’s need changed not all care plans regarding the same need were updated. Some care plans were not fully person centred because their ability to manage aspect of their care was not included.

Members of staff explained the procedures for safeguarding of vulnerable adults from abuse. They were able to tell us the types of abuse and their responsibilities to report abuse. We saw people approach the staff and seek interaction from them. We saw people respond in a positive manner to the staff on duty.

Risks were assessed and staff were knowledgeable about the actions needed to minimise identified risks. Risk assessments were devised on how to minimise risks identified.

The staff were supported to meet their roles and responsibilities. Staff had to attend training set by the provider as essential. The staff said the training was good, they attended refresher training and specific training to meet the needs of the people accommodated. However, the training matrix showed not all the training set as mandatory was attended by the staff

The views of people were gathered about the quality of the service. Members of staff knew people’s method of communication and knew this ensured people understood that they mattered. People were supported to access the community for example, visit to cafes. Staff responded to people when assistance was needed and to the various methods of interaction.

Quality assurance systems were in place to assess the standards of care provided. Where standards were no met action plans were developed on meeting the shortfalls identified.

A registered manager was in post at the time of our inspection visits. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were insufficient staff deployed to meet people’s needs. Members of staff said they were often “working short staffed and covering vacant hours was a struggle”. The registered manager confirmed there had been a 27 percent turnover of staff in the last 12 months. They said the provider was taking steps to attract good staff and to retain them for example, they had introduced incentives and investment in training. During our visits we saw the number of staff on duty did not reflect the rota. The team leaders spent significant periods of time contacting staff to cover vacant hours for four services. This meant the ratio of staff working with people was reduced.

Records were not always up to date. Daily reports and keyworker notes were not always completed by the staff and Medication Administration Records (MAR) were not signed for two people to indicate the medicines were administered.

Audits were used to monitor the standards of care and to ensure a safe environment was maintained. For example, health and safety, infection control and management of medicines. However, medicine management audits had not identified staff were not signing MAR (Medication administration records) charts following the administration of some medicines and that staff were not following the cleaning schedules for freezers and food safety guidelines.

Members of staff showed a good understanding of the safeguarding of vulnerable adults from abuse procedures. Members of staff knew the signs of abuse and the actions they must take should they suspect abuse. The one person giving us feedback said they felt safe with the staff and living at the home. The people we observed sought staff attention and did not show signs of agitation by the presence of staff.

Arrangements were in place to minimise risks to people and for people to take risks safely. Risks were assessed and action plans were developed on how staff were to minimise the risk.

Safe systems of medicine management were in place. The competency of staff was assessed before they were able to administer medicines unsupervised. Where people were able, they were supported to self-administer their medicines.

The induction programme for new staff was comprehensive and prepared them for the role they were to perform. Staff attended essential training set by the provider and other specific training needed to meet the needs of people at the service.

People were able to make daily living decisions such as activities, meals and routines. Members of staff showed a good understanding of their role in enabling people to make these decisions. Mental Capacity Act (MCA) 2005 assessments were completed for specific decisions such as dental treatment, access to the kitchen and for leaving the property. Best interest decisions made by people’s next of kin (NOK) or advocates relating to the sharing of information were not within the principles of the MCA. The NOK or advocates did not have legal power of attorney. Deprivation of Liberty Safeguards (DoLS) were in progress to the supervisory body for people subject to continuous supervision.

Staff had a good understanding of people’s preferences. We observed staff use a variety of approaches when they interacted with people. They had insight into the behaviours people presented and the response needed to reduce the potential of aggressive situations from escalating.

Support plans were developed to meet all aspects of people care and treatment needs which keyworkers [members of staff assigned to specific people] monitored monthly.

People were supported to maintain their ongoing health. Staff accompanied people on healthcare appointments. Records of appointments and the outcome of the visits were maintained. The hospital passports that were in place detailed important information about the person to help medical staff deliver care and treatment in the event of an admission.

Referrals were made for input from healthcare professionals for people with specific health conditions. The guidance given by healthcare professionals was used to develop action plans on meeting people’s changing needs.

People’s views were gathered at house meetings and questionnaires. The analysis of the surveys provided the registered manager with suggestions on improvements that were needed. An action plan to make improvements was to be developed.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service caring?

Staff told us they knew people well and for those people who were unable to communicate verbally, were aware of people's wishes and how they were feeling through body language, eye contact and specific routines. We observed staff interacting with people and found there were many examples of positive interactions where staff were kind and attentive. People were encouraged to do things at their own pace and staff were patient. Most staff were respectful towards people, however we found that one member of staff did not offer support when a person's dignity was compromised. We have advised the provider of this incident.

Is the service responsive?

The home provided services for people with a high level of need and records clearly demonstrated how care and support should be provided in line with people's wishes. People's weekly activity timetables had been devised around their personal preferences and activities which they enjoyed. People were able to change their minds about the daily activities they took part in and staff adapted these activities around people's wishes. Care records showed the home responded appropriately to changes in the level of people's support and personal care needs.

Is the service safe?

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We found there were appropriate policies and procedures in place and staff had been trained to understand when an application should be made.

People were protected from unsafe or unsuitable equipment because the provider had taken steps to ensure that equipment was maintained and fit for purpose. People in the home had access to wheelchairs which were serviced regularly and monitored for wear and tear. The risk of injury to people had been reduced as items such as televisions had been encased in non-breakable plastic surrounds which did not shatter upon impact. Regular health and safety checks were carried out to maintain a safe environment for people who lived in the home.

Is the service effective?

The home worked closely with other agencies to ensure people received timely and appropriate health care when required. People received a range of health and social care services ranging from behaviour management, speech and language, chiropody, dental and community nursing. Staff demonstrated they knew people well and how they communicated their wishes and feelings. One relative told us 'I am very happy with the care my family member receives'.

Is the service well-led?

People and their relatives had completed a satisfaction survey and the manager told us these would be used to inform any improvements to the service which was delivered. The provider operated a planned schedule of audits including staff training and supervision which ensured staff had the appropriate skills to support people appropriately. The home had monitored the retention of care staff and had taken steps to address issues of retaining staff. There were clear structures of accountability in place and staff were confident in their role and responsibilities.

We observed people used all areas of the home. We saw they made use of their bedrooms and enjoyed their hobbies for example, music and DVDs. On the day of the inspection most people were out in the morning in the community.

Staff we spoke with told us they enjoyed their work and felt well supported. We saw staff had received the appropriate training to care for people safely and effectively.

People were knowledgeable and confident about safeguarding vulnerable adults. They understood how people communicated their consent to care on a day to day basis.

Overall people's records were up to date and reflected their needs. Staff personnel records and people's care records were stored securely.

We observed care which was patient and caring and demonstrated staff understood people's needs. One person told us "it's good here"

We saw people's nutrition and hydration needs were met and risks were monitored.

There were enough suitably qualified staff to provide care and support.

The provider had the appropriate systems in place to monitor risk and assure quality

People who use the service may not be protected from the risk of abuse because the provider had not taken reasonable steps to ensure their safeguarding policy was fully implemented. Staff did not fully understand the signs of abuse or the role of external agencies. People who use the service may not have been aware of how to raise concerns about abuse.