About the service: The Old Rectory is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection there were 17 people using the service.

People’s experience of using this service:

The provider had failed to act to ensure improvements had been made within the service. This is the third consecutive time the service has been rated ‘Requires Improvement’ or ‘Inadequate’. Providers should be aiming to achieve and sustain a rating of ‘Good’ or ‘Outstanding’. Good care is the minimum that people receiving services should expect and deserve to receive and we found systems in place to ensure improvements were made and sustained were not effective.

Systems to monitor the service had not been effective in identifying the improvements that were still needed. People were not always protected from harm as action had not been taken where risk had been identified. People’s support was not provided in line with current legislation and best practice guidelines; this had resulted in people being placed at risk of harm. People did not always have a care plan which reflected how to minimise risks and record how they wanted to be supported. Staff had not received training to support people with complex behaviour.

There were not always sufficient staff to support people safely. Where people needed additional support to stay safe or prevent harm to others, staffing was not arranged to ensure people’s safety. The lack of staff support through the day meant some people did not receive individual respectful care and did not enable people to be involved with activities outside of the home. People had limited opportunities to engage with activities that interested them. Improvements were needed with how medicines were recorded, and accurate audits were not completed for the medicines kept in the home.

A new electronic care planning system had been developed, although people’s care plans did not always include information about how to provide their support or how to reduce identified risks. The system was not accessible in all parts of the home due to limited internet connection.

People could make everyday decisions. However, some people were not always supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service did not support this practice. Where restrictions required an urgent referral to support any restriction, this had not been recognised. CCTV had been installed in the home and although this was not currently in use, people had not been consulted and their consent had not been obtained for its use.

People’s dignity was not always respected. Where people needed supported to eat and drink, staff did not support people in a respectful and dignified way.

People were able to stay in touch with people who were important to them as visitors could come to the home at any time.

Staff understood how to support people with individual preferences and recognised and valued people’s diverse needs. People knew who to speak with if they had any concerns. People had access to healthcare services and felt they received the support they needed from staff. People knew who the registered manager was and were able to share their views about the service.

Rating at last inspection: Requires improvement. (Published January 2018)

Why we inspected: This was a planned inspection based on the previous rating.

Enforcement: Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up: The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service

This unannounced inspection took place on 13 and 15 November 2017. The Old Rectory provides accommodation for up to 26 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection, 14 people were using the service.

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.

At the last inspection on 13 March 2017, we asked the provider to take action to make improvements for risk management, assessing capacity to consent, providing personalised care and management systems. Some of these actions were completed and others required some further improvement.

Some risk assessments had been put in place and staff understood how to support people safely. However, not all risk was considered and learning from when things go wrong was not always implemented. People were not always supported to have maximum choice and control of their lives and staff did not always understand the safeguards in place to support them in the least restrictive way possible. We made a recommendation about improving risk management and one about improving staff understanding around restrictions made in people’s best interests.

Management systems had been implemented and actions were taken when areas for improvement were highlighted. Further management systems were in development to fully embed quality improvement; for example care plans audits.

There were improvements in the monitoring of people’s food and fluid to ensure that they remained well. The provider had good links with other organisations and healthcare professionals to maintain people’s health. They also developed effective relationships with external organisations to improve standards.

People’s care plans had been improved to include personal preferences and staff understood how to meet these. People were engaged in activities and leisure pastimes and a record of their life histories assisted with planning these.

Staff had received the training they needed to enable them to support people well. There were systems in place to assess their competency. They also had regular appraisals.

People had caring, supportive relationships with staff. They ensured that people’s dignity and privacy was upheld. They knew people well and understood how to comfort them if they were distressed. There were enough staff to meet their needs promptly and keep them safe. Safe recruitment procedures were followed.

The environment was planned to meet people’s needs and there were effective infection control processes in place.

Visitors were welcomed at any time. People and relatives knew the registered manager and felt there was an open door policy where they could raise concerns. There had been no complaints received.

This is the second consecutive time the service has been rated Requires Improvement under this registration.

This inspection was unannounced and took place on 13 March 2017. The service was registered to provide accommodation for up to 26 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection, 14 people were using the service.

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.

This location had a previous inspection when it was under a different named provider. However, the new provider was the same person as before, and the registered manager and staff remained the same. We have therefore referred to the previous inspection within this report.

Risks to people were not consistently assessed, monitored and reviewed. When people were not able to make decisions for themselves, the provider had not shown how their care and support was provided in their best interests. Staff were not always supported effectively to ensure they had the knowledge and skills to carry out their roles. People were not always supported to maintain a balanced diet and had limited choices for their meals.

People did not always receive care that was personal to them. People did not have the opportunity to participate in activities that interested them or provided stimulation. People’s care records were not always reflective of their individual needs. Not everyone knew how to raise concerns and complaints.

The provider was not meeting their registration requirements, as they had not informed us about specific incidents that had occurred. They did not have effective systems in place to monitor the quality of the service or to drive continuous improvement. The provider did not actively encourage people to contribute to the development of the service.

Staff understood their responsibilities to protect people from harm. There were enough staff to meet people’s needs and the provider checked staffs suitability to work with people. People received their medicines as prescribed and had access health care services.

Staff were caring in their manner and knew how to promote people’s dignity. They helped people to be independent and respected the day to day choices people made. There was a registered manager in post and staff were positive about working for the provider.

We found breaches 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 the report.