CQC report explained · a residential care home
What the CQC found at The Old Rectory Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2021
Targeted inspection was not rated; inspectors found no evidence of harm, but PPE disposal needed improvement.
This was a targeted inspection on 26 February 2021. It followed concerns about safeguarding and infection control, including care for people who had tested positive for COVID-19.
Inspectors spoke with six staff members and four relatives. They found safeguarding concerns were recorded and referred appropriately, and staff knew how to report and escalate concerns.
The home was clean and PPE was available. Inspectors found infection control arrangements were mostly effective, but the home was not always disposing of PPE according to its own policy. The provider acted on this feedback.
The service was inspected but not rated. This means the previous overall rating of Good, from 29 May 2019, was not changed. A targeted inspection does not assess the whole service.
Safeguarding processes
Safeguarding concerns were recorded and referrals were made to the local authority. Staff understood how to report concerns and escalate them if necessary.
“The provider recorded safeguarding incidents and evidenced referrals were made to the local authority when safeguarding concerns were reported to the service.” from the report
Infection control
Inspectors were assured that the home was clean, had reviewed its infection control policy and had access to PPE. Staff were following the latest guidance during the inspection.
“We found people were protected from the risk of acquiring infections and the service was clean.” from the report
Testing and vaccination
The home was accessing testing for residents and staff and was engaging with the government vaccination programme.
“We were assured the provider was accessing testing for people using the service and staff and engaging in the government's vaccination programme.” from the report
PPE disposal
needs fixingPPE was available and generally used safely, but disposal did not always follow the home's own waste policy. The provider acted on the inspectors' feedback.
“The provider needed to improve how they disposed of PPE, in accordance with their own waste disposal policy and to ensure the spread of infection was minimised.” from the report
- 01What changes have you made to PPE disposal since the inspection?
- 02How do you check that used PPE is disposed of safely and according to your waste policy?
- 03How are safeguarding concerns recorded, investigated and referred to the local authority?
- 04What infection control arrangements are currently in place for visitors and people who test positive for COVID-19?
- 05When is the next comprehensive inspection expected, and what improvements are being made before then?
This was a targeted inspection of specific safeguarding and infection control concerns; it did not assess the whole service or change the previous ratings. This explanation was written from the published report of 16 March 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2019
Rated Good; inspectors found safe, kind and well-organised care, with some records needing more detail.
This was an unannounced inspection on 29 April 2019. One inspector spoke with people living at the home, visitors, staff and managers. They also observed care and checked care, medicines, healthcare, training, complaints and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they were happy and supported by kind staff. Inspectors found that risks were managed, medicines were given safely, staffing met people's needs and staff understood their responsibilities.
Inspectors found some smaller gaps. Personalised information known by staff was not always written in care plans. A topical cream chart was recommended, and the home was asked to ensure staff removed protective equipment when leaving people's rooms.
The overall Good rating continued from the previous inspection in September 2016. The report says the registered manager had introduced better audits and checks, and had further plans to improve the home.
Managing risks
Inspectors found that risks linked to people's care were assessed and reviewed. Staff knew what actions to take to reduce the risk of harm.
“Risks related with people's care were assessed, reviewed and managed in a safe way.” from the report
Safe medicines support
Staff were trained and records showed medicines were administered correctly. Time-critical medicines were given at the right intervals.
“People received their medicines safely from trained and competent staff.” from the report
Kind and respectful care
People and relatives described staff as kind, patient and supportive. Staff protected privacy and encouraged people to remain independent.
“People said staff were patient with them, kind and people and relatives said they all got on well together.” from the report
Choice and activities
People were involved in everyday decisions and could take part in activities suited to their interests. Quieter activities and time in people's rooms were respected.
“People had access to activities, interests and hobbies that were tailored to individual needs and wishes.” from the report
Quality monitoring
The manager had strengthened audits covering areas such as weights, pressure care and equipment. Action plans were used when checks identified improvements.
“Safety and quality audits and checks were carried out by the registered manager.” from the report
Topical cream records
minorInspectors found that prescribed creams were given as directed, but recommended using a chart so staff could record that they were applied consistently.
“we recommended the staff completed a topical cream chart that would make sure, those creams were applied consistently.” from the report
Personal details not always in care plans
needs fixingStaff knew important small details about people, but positive approaches that helped were not always written in care plans. The manager agreed to review the plans.
“Positive approaches that worked well, were not always recorded so we recommended this be incorporated into plans of care which would help provide the person-centred care needed.” from the report
Protective equipment practice
needs fixingInspectors saw no infection-control concerns during the visit, but had been told of occasions when staff did not remove protective equipment after leaving a person's room.
“however we had been told of examples when staff had not always removed their PPE when leaving a person's room.” from the report
- 01Have all care plans been updated to include the personal details and approaches that staff know help each person?
- 02How are topical creams recorded now, and how do you check they are applied consistently?
- 03What action has been taken to ensure staff remove protective equipment when leaving a person's room?
- 04How do you review staffing levels if people's needs or the number of residents changes?
- 05What progress has been made with improving the garden and outside space?
This was an unannounced planned inspection covering the home, the care provided and all five CQC questions; the Good rating continued from the September 2016 inspection. This explanation was written from the published report of 29 May 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of The Old Rectory Care Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 31 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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