We carried out an unannounced comprehensive inspection of The Old Rectory Nursing Home on 20, 22 and 26 November 2018.

The Old Rectory Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or 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. The service is registered to accommodate up to 35 people in one building. It specialises in providing support to people who are living with dementia and other age-related conditions. At the time of the inspection 27 people were living at the service one of whom was in hospital.

A registered manager was in place. 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. The registered manager had not been working at the service since 25 June 2018 and was due to return to work in January 2019. An acting manager was covering the registered managers absence two days a week.

The provider had not ensured the arrangements in place for the management of the service were effective. The acting manager did not have sufficient time to undertake their management responsibilities. Roles, responsibilities and accountability arrangements were not clear and incidents had not been reported to the CQC as required.

The systems in place to monitor and assess the quality of the service were ineffective and had not identified shortfalls in the quality and safety of the service people received. Where shortfalls had been identified, action had not been taken to make the required improvements.

The provider had not sought guidance to provide an environment that could meet the needs of people living with dementia. There had been no consultation with people or their family members before changes had been made to the environment. The environment was not kept free from hazards and did not aid the orientation of people living with dementia. There was not enough seating or dining tables to accommodate the number of people living at the service.

There was an inconsistent approach to safety that sometimes placed people at risk. Risk assessments were not always reviewed as needed and staff did not always follow good practice when moving and positioning people, which increased the risk that harm could occur.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible. Staff did not always demonstrate a good understanding of gaining lawful consent.

There were processes in place to respond to formal complaints but there were no systems in place to monitor themes and trends of day to day concerns that were raised.

People's care plans and care assessments did not always consider the full range of people’s diverse needs and were not always up to date and accurate. The opportunities for people to engage in social activities was limited and people were not consistently supported to engage in activities they found stimulating and enjoyable.

Although people's relatives felt staff were kind and caring, some aspects of the environment did not protect people's privacy. Some staff practices were task lead rather than person centred and did not promote people's dignity.

Staff training was not always up to date and staff did not have access to policies and procedures that reflected current good practice guidelines and legislation. Staff felt supported by the management team but did not receive regular supervision meetings. They did not have the opportunity to attend regular team meetings.

People enjoyed the homemade meals and their dietary requirements were met. Our observations were that people were comfort

We carried out an unannounced comprehensive inspection of The Old Rectory Nursing Home on 16th January 2017.

The Old Rectory Nursing Home is registered to provide accommodation with personal and nursing care for up to 31 people who live with dementia. The home is set within its own grounds with car parking facilities.

A registered manager was in place and was present during our visit. 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 in April 2016, we asked the registered provider to display the ratings from the previous CQC inspection as failure to do this was a breach of regulation 20A. This visit found that this had been addressed with ratings now prominently displayed.

Prior to this inspection we received a concern about poor communication with relatives in relation to the changing needs of people and the availability of an access to records policy and procedure. We looked at those concerns as part of this inspection. We found evidence that relatives were contacted when events or issues occurred which affected their relations and this was confirmed by relatives we spoke with. We found that while an access to records policy was available; this needed to be reviewed as did other policies and procedures.

Relatives told us that they felt that their relations were safe living at the Old Rectory. Observations of care found that people were comfortable and relaxed with the staff team.

Staff demonstrated a good understanding of the types of abuse that could occur and the action that they needed to take in the event of harm occurring or suspected harm. Staff were aware of the whistleblowing process and of external agencies they could refer concerns onto. Staff also understood the principles of the Mental Capacity Act 2005. The best interests of people who did not have the capacity to make decisions were evidenced.

The premises were clean and hygienic with no hazards present which could present a risk to people who used the service. Personal emergency evacuation plans (PEEPs) were available for each person in the event of them having to be evacuated in an emergency.

Risk assessments outlined the specific risks people faced in their daily lives. This enabled people to receive safe care and treatment.

Medicines were safely managed. All medication was safely secured and could be accounted for. The registered manager had processes in place to ensure that medication was administered safely.

There were sufficient staff on duty during our visit to keep people safe. Staffing rotas confirmed that these levels were maintained and this was confirmed by people who we spoke with. Recruitment records included all the necessary checks to ensure that people who used the service were supported by staff who were suitable to care for vulnerable adults.

Staff received training and supervision appropriate to their role. Staff also received annual appraisals which gave them the opportunity to discuss their practice and areas of future development.

The nutritional and hydration needs of people were taken into account with people being offered choice and support with eating and drinking. Risk assessments were in place to ensure that people were not at risk of malnutrition.

People who used the service were living with dementia. Whilst steps had been taken to orientate people within the building, we recommend that the registered provider refers to good practice guidance to ensure that the environment is fully dementia friendly.

People’s privacy and dignity was promoted and they were supported in a discreet, friendly and respectful manner.

Care plans were available for all people. These were person centred and were reviewed regularly. Th

The inspection was unannounced and took place on the 5 and 7 April 2016.

The Old Rectory provides nursing care and accommodation for up to 35 people. At the time of the inspection there were 26 people living at the service. The service is situated in the village of Capenhurst which is six miles from Chester.

The service had a manager who had been registered with the CQC since June 2015. 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.

We carried out an unannounced comprehensive inspection of this service on 12 November 2015. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to Regulations 12, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. 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.

The overall rating for this service is ‘requires improvement’. This is because, despite improvements having been made, a higher rating requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

The registered provider had failed to display the current rating for the service in line with Regulation 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the last inspection there were insufficient numbers of staff in place to keep people safe and accidents and incident levels were high. At this inspection we found that there were enough staff on duty to maintain people’s safety, and the number of accidents and incidents had significantly reduced.

During the last inspection we found that recruitment records were not sufficient to ensure people were protected from harm. At this inspection we found that the recruitment process was more robust. Applicants provided two references, one of which was from a previous employer, and they had also been subject to a check by the disclosure and barring service (DBS). The DBS helps employers decide whether people are of suitable character to work with vulnerable people.

During the last inspection we found areas of the environment that needed improvement. At this inspection we found that the boiler had been repaired, and whilst one shower room had been made into a storage room, the other was functioning and was accessible for people’s use. The fire service reported that they were satisfied with the changes that had been made.

At the last inspection there were issues around infection control. During this inspection we found the service was free from unpleasant odour, and that bedrooms had been redecorated and carpets replaced with laminate flooring the help maintain cleanliness. Staff used personal protective equipment (PPE) as appropriate to help minimise the risk and spread of infection.

During the last inspection staff were not always supported to complete training required for them to carry out their role effectively. At this inspection staff had a good understanding of the MCA, and had completed dementia awareness training. There was a formal induction process in place for new staff, and the registered manager kept a record of training that had been completed.

At the last inspection there were aspects of the environment that were not suitable for people living with dementia, and the communal space could not accommodate people living within the service. At this inspection we found that people’s doors had been decorated to include personal

This was an unannounced inspection carried out on the 12 November 2015.

The Old Rectory Nursing Home is registered to provide accommodation with care and nursing support for up to 31 people who have dementia. The home is set within its own grounds with car parking facilities.

The service has a registered manager. 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.

During the inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. We issued warning notices to the registered provider and the registered manager.

The last inspection was carried out on the 10 July 2014 and we found that the service was compliant with regulations.

People who used the service were not fully protected from harm. We found that there were insufficient numbers of staff in place to ensure people’s safety, and that appropriate action was not being taken to remedy this.

The fabric of the building was in need of repair and the boiler had been broken for two weeks prior to the inspection. The registered provider had not worked promptly to remedy this situation and there were insufficient processes and risk assessments in place to ensure that those people without heating and hot water remained safe. There had been issues identified with the fixed electrical system and no effort had been made by the registered provider to remedy this.

There were inadequate processes in place to prevent the spread of infection. The sluice room on the first floor did not contain a functioning sluice and there was no clinical hand wash basin for staff. We found that several bins throughout the service had an open top despite this having been identified as an issue in a recent infection control audit. We found that bedding was being stored on the floor in a linen cupboard which is not in line with Department of Health guidance.

Recruitment processes were not robust enough to protect people from harm. We looked at the recruitment files for two staff members and found that in both cases references had not been sought from a previous employer. The interview process had not explored periods of unemployment or touched upon previous criminal convictions.

Staff we spoke with did not have a basic understanding of the Mental Capacity Act 2005, however they demonstrated that they would seek consent from people prior to delivering personal care. Staff had not received training around caring for people with dementia and there was no system in place to monitor whether staff training was up-to-date.

The environment was not suitable for people with Dementia. Corridors and people’s doors were uniform and easy for people to become disoriented within. There was insufficient communal space to accommodate all the people using the service and the thoroughfare accessing other parts of the building was used as a main lounge.

The dining area was small and was not able to accommodate all the people using the service, which meant that not all people had the choice of sitting down at the table to eat their meals.

People told us that they enjoyed the food, and there was evidence to suggest that consideration had been given to people’s special dietary needs.

Staff received supervision from the registered manager, however there was no system in place to monitor which staff had received supervision and which staff had not. This would impact upon the consistency of supervision.

Staff were not always able to respond to people’s needs in a timely manner due to low staffing levels. People on the first floor received less interaction from staff outside of having their personal care needs attended to. The bathrooms on the first floor were not in use and we were informed that people on the first floor were provided with a full body wash rather than having a shower or a bath.

People felt able to raised concerns with the registered manager, however they did not have confidence that their concerns would be addressed by either the registered manager or the registered provider.

The service was not well led. People felt that there was a lack of resources being made available to the service from the registered provider which had an impact upon the overall quality of the service. Both the registered manager and the registered provider had failed to identify issues with staffing and poor recruitment processes. We found that the registered manager had not made formal plans to address issues raised following audits by infection control and the fire service. This meant that the registered manager was unable to demonstrate whether action was being taken to address these issues.

Audits were completed by one of the nursing staff, however there was no management oversight of this process or formal analysis of where improvements could be made.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

Ensure that providers found to be providing inadequate care significantly improve.

Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We considered our inspection findings to answer questions we always ask; Is the service Safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of what we found;

Is the service Safe?

We contacted the local authority before this inspection. They told us they had received no further safeguarding concerns in relation to the home since our previous inspection. One safeguarding concern that had been reported in December 2013 was currently on going and we await the outcome to be made known. The provider had responded appropriately to any allegation of abuse and involved both the local authority and the Commission.

We were given a tour of the home at the start of our inspection. On entrance to the home a mild malodour was present. This was not the case throughout the rest of the home. We examined the carpets throughout the home and found they presented no safety hazards to people. However, the carpets in the communal corridor on the ground floor did look worn and in need of replacement. This was also not the case throughout the rest of the home. We spoke with the head of services about this. She was able to provide evidence that the home was to be re-carpeted in the near future.

We found the provider has taken steps to provide care in an environment that is suitably designed and adequately maintained.

Is the service effective?

It was clear from our observations and discussions with care assistant's that they had a good understanding of people's care and support needs and that they knew people well. One relative told us; “I am really impressed as the change for Mum coming here from home was very traumatic for us and her. There is nothing I am really concerned about. I would give it five stars".

Staff told us that they felt well supported by the management team and they had the information they needed for their roles.

Is the service caring?

People were supported by kind and attentive staff. Staff spoke to people in a caring and compassionate manner. When people became confused and upset, staff dealt with the situation calmly and were attentive to people's needs. A person who used the service told us; "Everything is ok and they look after us. I have nothing to moan about”.

Is the service responsive?

People's needs had been assessed before they moved into the home. People had access to activities that were important to them.

Records and discussions with staff showed that where there was a concern about a person's health needs the advice and support of various professionals such as GP's, tissue viability nurses, social workers, the falls team and community psychiatric nurses had been sought. Records suggested that any instruction given had been followed.

Is the service well led?

Following concerns raised at previous inspections, changes to the senior management team had been made. A new head of services had been appointed nine weeks prior to this inspection.

On 10 February 2014 we served a fixed penalty notice to The Old Rectory Limited for failing to have a registered manager in place at The Old Rectory Nursing Home. A fine of £4,000 was paid. A manager application had since been received and was being assessed at the time of this inspection.

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. Staff understood their roles and responsibility to maintain people's safety. The service had recently sent out questionnaires to all relatives. Although the previous senior management team had conducted this process within the last year, the head of services thought that she needed to ascertain people's views for herself.

We did not speak to people who used the service during this inspection. This was because at our previous inspection we found that people experienced care, treatment and support that met their needs and protected their rights.

During this inspection we found that the service had acted in a way that protected people from the risk of abuse. All incidents had been reported to us and the local authority as required.

At this inspection we found that appropriate arrangements were in place for obtaining and handling medicines. This meant that the medicines people needed were available in the home. The manager had recently carried out a check (audit) to see if medicines were being used safely. This meant that people were protected from harm.

We found that fire alarms were tested weekly with fire drills taking place on a regular basis. In addition to this, each person who used the service had their own personal evacuation plan.

We found that eight people who used the service required the use of bed rails. We examined the eight beds and found all were profile beds with bed rails fitted securely on both sides covered with bed rail protectors. Mattresses were also the appropriate size for each bed.

At this inspection we saw the home had started to use the audit tools in place for care planning, environment and accidents / incidents. We saw there were processes in place to address any concerns that were identified.

During this inspection we found the care records for people who used the service had been completely reformatted. The new style records contained information about the life history of each person and provided detailed guidance for staff on how people wished to be supported.

We saw staff were sitting and talking to the people who used the service keeping each person involved in discussions. Staff spoke to people with respect and were aware of their role to maintain people's safety.

Most people living in the home had a diagnosis of dementia and did not know, or were unaware of what medicines they were prescribed. This meant that they were unable to talk to us about their medicines in a meaningful way.

We found the people who used the service were supported by staff that had suitable skills and competencies.

We found the service had not complied with a legal requirement to ensure that we are notified and kept up to date with all outcomes in relation to the safeguarding of people who lived at the service.

We found the service had introduced a new system so that a regular assessment of the homes environment, care planning and clinical governance was conducted. However, the system that was developed was yet to be put into practice.

Following our last inspection of The Old Rectory Nursing Home on 9th August 2012 we asked the provider to take action after we identified concerns in relation to the planning of care and staffing, particularly at meal times. During our last inspection we found people did not always have the opportunity to be involved in their own care planning and don’t always have the opportunity to say what was important to them. On this inspection we found that people who used the service and/or their advocates had still not been consulted about this. There were no lifestyle choices plans in place. The manager told he was recently appointed to the role and had put plans in place to address the concerns immediately.

We spoke with two relatives of people who used the service. Comments from them included "The staff keep me involved. They ring straight away if something is wrong" and "The staff are really good. I can't fault them."

We saw that a new dining room was very close to completion. The new manager told us this would address concerns in relation to staff not being able to support people who used the service during meal times. Our previous inspection identified concerns about people who used the service eating in three separate rooms. They were seen waiting to be supported to eat while staff assisted others. During this inspection this was not the case.

We found staff were supported in their roles and given opportunities for professional development.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met. The inspection team was lead by a Care Qulaity Commission (CQC) inspector joined by an Expert by Experience who has personal experience of using or caring for someone who uses this type of service.

We spoke with eight people living at the home. Their comments about the service they received included “I’ve never known as any disrespect”, “the staff are alright, if you are alright with them then they are alright with you.” One person told us “I can choose my own clothes that I want to wear but I don’t always bother. I get up when they come to dress me and I go to bed when they say time for bed.”

We spoke to six people who were eating their lunch in the lounge area and four people eating their lunch in the dining room. People told us that they had enjoyed their meal.

Relatives of people living at the home told us “she’s generally asked what she would like from the menu. If she doesn’t eat it they take it away and replace it with something else.” Another relative told us that their relative was waiting for an eating and drinking assessment from a healthcare professional. They told us that their relative “has sandwiches in the evening with soft fillings which he seems able to eat but the pureed food doesn’t look very nice. He has different food than on the menu – something more suitable for swallowing.”

Relatives of people living at the home told us “the manager has been supportive to the family with outside concerns, I would go to him if I had any concerns.” “I’d speak to the staff if I didn’t think he was being looked after properly” and “I would speak to the staff if I was worried.”

We spoke to six people who all told us that they liked the staff. One person told us that “they were very kind” and another said “I like them.”

Visiting relatives told us “the staff have to prioritise on occasions and if it’s a minor thing it may take a few minutes before they help” and “I think staff need more training in Alzheimer Disease. They don’t spend enough time just chatting to residents.”