About the service: The Old Rectory is a ‘care home’ for up to 34 people. The home supports older people, many of whom are living with dementia, across two floors. When we inspected, there were 31 people living in the home.

People’s experience of using this service:

¿ Without exception people were positive about living in the home, and felt staff were caring and met their needs.

¿ People’s needs were met on an individual basis, and they received support according to their preferences.

¿ Staff treated people respectfully and ensured they had a right to privacy, and supported them to maintain independence where possible.

¿ People received a choice of meals and were positive about the quality of the food they received.

¿ There were activities to participate in and people could follow their interests with support from staff.

¿ People and relatives were positive about staff and the registered manager. Staff knew people and their needs very well, and built good relationships with them.

¿ The registered manager was visible and approachable, and people felt they could comfortably raise any concerns they may have.

¿ Quality assurance systems had improved since our last inspection and there was ongoing monitoring of the service.

Rating at last inspection: Requires Improvement (published 4 May 2018). This service has been rated Requires Improvement at the last two inspections. At the last inspection, there was a continued breach of one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected: Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe and well-led to at least good. They sent us an action plan with this information, and we met with the providers to discuss our concerns about the home and having the rating of requires improvement at the last two comprehensive inspections. This inspection was completed in line with the timescales required for services rated requires improvement.

Follow up: We will continue to monitor the service in line with our inspection schedule for services currently rated Good.

The inspection took place on 19 and 20 March 2018 and was unannounced.

At our last inspection carried out on 12 December 2016, we found three breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of Health and Social Care Act 2008 (Registration) Regulations 2009. Although some improvements had been made within the areas of breaches, some further improvements were needed.

The Old Rectory is a ‘care home’ for up to 34 people. The home supports older people, many of whom are living with dementia, across two floors. When we inspected, there were 32 people living in the home. There was one room which was being shared by two people. The rooms had en-suite toilets and sinks, and there were other communal bathrooms with showers and baths on each floor.

People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was a registered manager in post. The registered manager at the home had been registered with CQC since September 2017. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We last inspected this service on 12 December 2016, and we found three breaches of regulations. We completed this comprehensive inspection to see if the home had been improved in these areas. At the previous inspection in September 2015, we had also asked the provider to take action to make improvements in respect of the quality of care that was provided to people.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, caring, responsive and well-led to at least good. They had not managed to make all the improvements needed to increase the overall rating of the home. Therefore, we remain concerned that the provider has not implemented effective quality assurance systems in a timely manner to ensure full oversight of the areas previously identified as a concern.

There had been improvements in infection control and the home was clean, and the registered manager completed a further risk assessment needed. There were some improvements required to the oversight of infection control within the home to ensure actions were taken when needed.

We found that risks were not always fully mitigated as far as is practicable because not everyone was able to ask for support from staff. This was addressed shortly after the inspection. Risks to people were covered in their care plans and there was guidance for staff on how to mitigate risk.

The registered manager had overlooked safeguarding notifications which they sent us shortly after the inspection. They sent these immediately after the inspection. We found that improvements were needed in the systems to assess, monitor and improve the service, as some concerns had not been identified by the provider.

There were effective systems in place for the registered manager to observe whether staff had seen people, however these were not always used to full effect to check that people received care according to their care plans. However, there had been a decrease in falls and people were safer since the electronic care planning system allowed the registered manager to have a better oversight of people in the home.

Medicines were administered as prescribed, and the registered manager had taken action when errors were made. Improvements were needed to the care planning around ‘as required’ (PRN) medicines, and the registered manager completed these immediately. Improvements were required to ensure the safe storage of

This inspection took place on 12 December 2016 and was unannounced.

The Old Rectory Care Home is a service that provides accommodation and personal care for up to 34 people. During the inspection visit, there were 32 people living within the home.

There was a registered manager employed at the home. 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 and associated Regulations about how the home is run.

At the last inspection on September 2015, we asked the provider to take action to make improvements in respect of the quality of care that was provided to people. At this inspection, we found that some improvements had been made but that further improvements are required. Some areas of the home and some equipment people used were unclean. Staff were not always responsive to people’s individual needs and the systems in place to assess, monitor and reduce the risk of people receiving poor care were not always effective. Some people’s care had not been fully planned for and some records in relation to their care contained inaccurate information. You can see what action we have told the provider to take at the back of our report.

Staff had received appropriate training and there were enough of them to meet people’s care needs. However, they were often very busy particularly in the morning and therefore did not always have time to spend with people interacting with them or providing them with stimulation to enhance their wellbeing.

The staff were kind and caring and they provided people with choice so they could make decisions about how they wanted to be cared for. However, people’s dignity and privacy was not always upheld.

Systems were in place to protect people from the risk of abuse. Staff sought advice from other healthcare professionals and acted in a timely manner when they identified any concerns about people’s health. People had access to a good choice of meals, snacks and drinks. The staff made sure people received enough food and drink to meet their individual needs.

The staff requested people’s consent before they provided them with care. Where people were not able to give consent, the staff made sure that they took any decisions they made on their behalf in the person’s best interests. People received their medicines when they needed them.

There was an open culture where people and staff could raise concerns if they wanted to. These were listened to and promptly dealt with. The people we spoke with were happy living in the home and the staff were happy working there. Staff were supported to progress in their roles if they wished to do so.

The registered manager had plans in place to improve the environment for people living with dementia with the ultimate aim to improve people’s quality of life and wellbeing.

This inspection was unannounced and took place on 2 September 2015.

The Old Rectory care home is a service that is registered to provide accommodation and care to up to 34 older people, some of whom are living with dementia. On the day of our inspection, there were 30 people living at The Old Rectory.

There was no registered manager working at the service. The registered manager had resigned from their post in March 2015. A new manager had started working for the service shortly after this date but they had resigned a month prior to our inspection. The provider was interviewing for a new manager on the day of the inspection. 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 and associated Regulations about how the service is run.

At this inspection we found that the provider was in breach of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to failures to provide safe care and treatment, to monitor the quality of the service provided effectively and to make sure there were enough staff working who had received the required training to keep people safe and meet their needs. You can see what action we told the provider to take at the back of the full version of the report.

Some risks to people’s health and safety were not being managed well and there were not always enough staff in place to meet people’s individual needs. The provider could not clarify whether staff had received enough training to provide them with the knowledge and skills to meet people’s needs and people’s medicines were not managed safely.

People were asked for their consent before the staff provided them with care. However, there was a risk that those people who were unable to consent to their own care were not always having their rights protected. Some people were not always treated with dignity and respect.

There were activities on offer to complement people’s hobbies and interests but some people were not protected from the risk of social isolation.

The provider had not effectively monitored the quality of the service to make sure that people received safe and appropriate care and there was currently a lack of clear leadership in place.

People and relatives felt confident to complain if they wanted to but were not sure who they needed to complain too.

People were protected from the risk of abuse and the staff were polite and courteous to people when they provided them with care.

People received enough food and drink to meet their needs and saw other healthcare professionals such as GP’s and nurses when they needed to.

We have made recommendations regarding following the principles of the Mental Capacity Act 2005 when making best interest decisions on behalf of people.

A single inspector carried out this inspection. The inspection followed up on concerns we had found at our inspection carried out on 3 April 2014, concerning care records. We focussed on the key questions relevant to this inspection: Is the service safe? Is the service effective? Is the service caring? Is the service responsive to people’s needs?

Below is a summary of what we found. The summary describes the records we looked at to help us form our judgement. As part of this inspection we spoke with staff but we did not speak with people using the service on this occasion. If you would like to see the evidence that supports the summary, please read the full report.

Is the service safe?

We looked at the care records of four people with varying needs and dependency who were living at The Old Rectory on the day of our inspection. The records showed that care plans were in place, which provided guidance to staff about how each individual was to be supported. We saw that the daily care reports were up to date, although there were some gaps in the records that recorded the personal care provided each day.

Risk assessments were in place and these informed the risk reduction plans. They set out what action was required of staff to ensure that risks were managed and minimised. This meant that people received the care and support they needed to keep them safe.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to all care services. Proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

The care records showed that the service liaised with health and social care professionals appropriately. We noted that health professionals were contacted quickly when advice and guidance was required. GP, community nurse, dietician and consultants’ visits were recorded clearly and there was evidence that changes were made to people's care plans to reflect any prescribed alterations in the care to be provided.

Is the service caring?

The care records demonstrated that the person’s individual choices and preferences were considered when they were written and subsequently reviewed. Some of the care records contained the person’s signature to show that they agreed and consented to the plan of care. Efforts had been made to ensure that the personal history of people was recorded where possible so that staff understood what was important to each person.

Is the service responsive?

The care plans were kept under review and alterations made to them to reflect any changes in the needs of the person. We saw that care plans were reviewed each month. We also noted that the care plans were audited periodically by the registered manager to ensure they were accurate and up to date.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

This is a summary of what we found-

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were warm, friendly and respectful and that they offered choices and encouragement to people. One person told us, "I'm very happy here and can't fault the place." Another person said, "Staff speak to me nicely and they are caring. They help me to wash and dress in the morning." A relative told us, "We are very pleased with the care provided."

People told us they received the care and support they needed and had agreed to. People's interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes and preferences.

Is the service responsive?

People were able to access a variety of activities at the service. These included group and one-to-one activities and also outside entertainments.

People using the service and their relatives had completed an annual satisfaction survey. One person told us how their comments had resulted in a change to the way their care was given.

People told us they knew how to complain and believed they would be listened to and their concerns acted on. One person told us, "I speak to staff if I have any concerns." We looked at how complaints had been dealt with, and found that the responses had been open, thorough and timely. People could be assured that complaints were investigated and action was taken as necessary.

Is the service safe?

People told us they felt safe and that they were treated with respect by staff. The service was clean and hygienic although some areas had not been well maintained. Refurbishment plans needed to commence in order to keep people safe.

The registered manager set staff rotas that took people's care needs into account. This meant there were sufficient numbers of qualified, skilled and experienced staff on duty. This helped to ensure that people's needs were always met.

Is the service effective?

Some people had signed to show their agreement with the content of their care plans. None of the people we spoke with were aware of what was in their care plan. Some of the care plans and risk assessments had not been reviewed regularly and were therefore not able to support staff consistently to meet people's needs.

Visitors we spoke with confirmed that they were able to see people in private and that visiting times were flexible.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing people's needs and involving people in planning their care.

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed. As a result the quality of the service was continually improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and this helped to ensure that people received a good quality service at all times.

We spoke with three people using the service, a visitor and a visiting professional. We also used SOFI to see the experience people had of living at this home.

We were told that people liked living at the home. One person said, "It's alright here, the staff are nice". Another person was able to make us understand that they were happy and enjoyed living at the home by smiling and nodding their head. A visitor told us they were able to visit whenever they wished and were always made to feel welcome.

Our observations showed us that people were encouraged to be as independent as possible, with staff providing support and encouragement when needed. The interactions between staff and people at the service was always warm and friendly. People joked and laughed with staff and many joined in with an activity during the afternoon.

We saw that visiting professionals were listened to by staff and advice and guidance recorded so that staff could follow treatment plans as described. Professionals told us that staff acted on their advice and referred appropriately so that interventions were timely.

Medication records were inaccurate and unreliable. There were gaps in the records and medicines not given when signed to say they were taken. Action is required.

People knew how to complain, although one person said they would prefer to talk with their relative first. We saw one person speaking with the manager about their concerns and they were listened to and action taken.

We did not speak to people using the service on this occasion because our visit was undertaken to see what progress the home was making in respect of people's care files. People's needs had not been kept under review and care plans providing staff with guidance about how a person's care and support should be delivered were not in place when we visited on two occasions earlier this year.

During this visit, we saw evidence that people's needs were being assessed and care plans written so that they received appropriate care and support. Care files contained all the information we would expect to find in order that people received individualised care and support when they needed it. The files contained guidance to staff about how care should be delivered and we saw risk assessments and risk reduction plans that helped to keep people safe.

We discussed with the line manager how the service was going to ensure it remained compliant with regulations and we were told that a review and reassessment programme had been developed. We saw this programme pinned to the wall so that staff were fully aware of when each care file needed to be reviewed.

We did not speak to people as part of this inspection on this occasion.

Seven people were spoken with, either in private or in communal areas. One person said they preferred to stay in their own room to watch television or to read. They said their days were, “Monotonous.”

People we spoke with said the food was good although it depended on who was cooking. One person described the food on occasion as being, “Like school dinners.” However, one other person said, “The food is fine and the staff are always kind and friendly.”

Some people said they had never been asked about their care and how they would like to be supported. Another person said, “There are not enough staff and no activities I like to join in with.” They described occasional musical afternoons that were not to their taste.

People told us they would speak with the manager about things that concerned them. They said the manager always listened to them and resolved their concerns for them.

During our visit to the home we spoke with two people who live at the home. They told us they liked living there and that the staff are kind and helpful. One person in particular said that she goes out for a walk when she wants to and staff know when she has gone out.