Inspection on 26/09/07 for Loreto Cottage Care Home

This inspection was carried out on 26th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Loreto Cottage Care Home 30/01/07

Loreto Cottage Care Home 05/01/05

Loreto Cottage Care Home 13/05/04

Loreto Cottage Care Home 16/12/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Loreto Cottage Care Home 1-2 Spring Lane Mapperly Plains Nottingham NG3 5RT Lead Inspector Karmon Hawley Key Unannounced Inspection 26th September 2007 11:15 Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Loreto Cottage Care Home Address 1-2 Spring Lane Mapperly Plains Nottingham NG3 5RT 0115 926 9357 F/P 0115 9267325 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Margaret Dobbin & Mr James Dobbin Mr Seamus Connolly Dobbin, Miss Sinead Dobbin Mr Seamus Dobbin Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category LD Date of last inspection 30th January 2007 Brief Description of the Service: Loretto Cottage is a converted and extended property, which accommodates sixteen adults with a learning disability. One resident is accommodated within a separate building within the grounds. Some local amenities are conveniently located near the home and transport provided by the home means residents can go further a field. All rooms are single and accommodation is on three floors. The residents have access to a range of activities and clubs on a regular basis and are afforded the opportunity to attend church weekly if they choose to. The current weekly fees range from £307 upwards depending on service users needs. All relevant information is made available on the point of enquiry. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken by an inspector reviewing all the previous inspection records available, looking at information provided by the manager about Loreto Cottage and by undertaking a visit to the service with the inspector using a method called “case tracking.” “Case tracking” involves identifying individual service users who currently live at the home and tracking the experience of the care and support they have received during the time they have lived there. The inspector also checked that information provided by the manager matched individual experiences of the service user living at the home by talking with them and observing the care received. General records maintained by the home were looked at to ensure these were maintained and provided positive outcomes for service users. As the majority of service users were out on the day of the visit only a small view of service users opinions are included in this report, however there are views of relatives included in the quality assurance section. What the service does well: What has improved since the last inspection? The manager and staff have made many improvements since the previous inspection. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 6 All service users have now been issued with terms and conditions of the home and contracts thus ensuring they are fully aware of the cost of the service and the facilities on offer. The majority of support plans have now been rewritten along with risk assessments. These are in depth and cover service users specific needs thus ensuring appropriate support is offered and service users remain safe. Plans of care are reviewed on a six monthly basis or more frequently if needed so that any changes in service users needs or support needed is identified. The recruitment policies and procedures have been improved and all new staff undergo a POVA 1st check and criminal record bureau check, they do not commence employment until these have been returned and are declared satisfactory. Staff training has continued to develop and staff have undergone training in specialised interventions such as giving emergency medication for an epileptic seizure to ensure the safety of service users. Compulsory training has also developed such as adult abuse procedures, health and safety and induction training to ensure that staff are competent to meet service users needs and ensure they are fully protected. All staff now receive regular supervision sessions offering them time to discuss their training and development needs and service users welfare. The provider now sends a monthly report to the Commission for Social Care Inspection to inform them that the home is running well and improvements continue. Formal quality reviews have begun to ensure that monitoring of the service is undertaken thus ensuring service users have more say in the running of the home. The manager now informs the Commission for Social Care Inspection of any untoward incidents to ensure that the home can be effectively regulated. Financial records for each service user are now kept at the home so these may be regulated and thus service users finances further protected. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users receive all the information they need to make an informed decision and are assured that their individual needs will be assessed and met prior to making a decision to move into the home. EVIDENCE: Since the previous inspection all service users have been issued with contracts and terms and conditions of the home, ensuring they are aware of the cost of the fees and the services on offer. These were kept in the manager’s office to ensure that confidentiality is maintained. Within support plans there was documentation that highlighted that discussions about financial arrangements had taken place. The manager visits prospective service users within the community to carry out a preadmission assessment prior to admission to ensure that the service is able to fully meet their needs. Prospective service users may also visit and spend time at the home before they make a decision to move in. Within the information sent to the Commission for Social Care Inspection the admission procedure was clearly outlined. There were up to date assessments of needs in all service users case files seen. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are fully met and they are enabled to lead an ordinary life with support offered from staff. Service users are facilitated to make their own choices and decisions. EVIDENCE: Service users support plans cover the activities of daily living and are based upon ensuring they lead an ordinary life with support offered as required. The plans were very personalised and reflected service users needs, choices, likes and dislikes. They gave an in depth picture of service users personalities and the life they lead within the home. The manager stated that they were in the process of updating plans of care and risk assessments and he had nearly completed these, two of the plans seen had been updated. In the updated plans appropriate support plans were in place and also risk assessments for highlighted risks. Where a service user experienced epilepsy a risk assessment was in place, it covered part of the emergency procedure to take should the service user experience a seizure in the bath, however did not cover the procedure to take should it occur at any other time, this was discussed with Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 11 the manager who stated that they would include this in the risk assessment. There was evidence that seizures had occurred in the daily records and also that staff had dealt with these effectively and appropriately. Reviews of the support plans could clearly be evidenced within each case file tracked. Staff discussed service users needs and how they supported them to meet these. When asked about managing challenging behaviour they were able to offer the management strategies they used to ensure that service users were fully protected. The service user spoken with said, “staff are very good, I tend to look after myself but staff are there to help me when I need it.” The staff described the routine of the home as being flexible and service users are enabled to make their own choices and decisions. There were support plans in place, which confirmed that this was taking place. One service user spoken with said that they are able to do as they please and generally make there own decisions about things. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are enabled and supported to partake in activities of their choosing thus leading a fulfilling and purposeful life. Service users are supported to engage with the local community and maintain relationships with relevant others. EVIDENCE: On the day of the visit the majority of service users were out, either at college, daycentres or work; relevant support plans were in place for this. When service users are at home a range of activities are on offer should they choose to join in; these include activities such as discos and karaoke, watching films, cooking, beauty therapy and football. Service users are also supported to go to the cinema, bowling or the pub if they choose. The routine of the home was described as being flexible and service users may choose to spend their time as they wish. One service user spoken with confirmed this and said there were activities on offer but they did not always want to join in, so they occupied themselves. Some service users also attend clubs in the evenings such as the Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 13 Loreto Club where they can meet up with friends. Staff spoken with discussed the level of support offered to service users and the activities available, however they also acknowledged that on occasion some service users were just happy to sit and watch television in the evening as they had been out of the house all day. Support plans in place demonstrated that service users are enabled to use facilities and services in the local community and also maintain relationships with family and friends. One service user spoken with said they often go out with staff and they receive visitors on occasion. Support plans also showed that service users visit and spend time with their family. Staff discussed how they support service users in developing living skills by working with them, sharing household tasks, cooking light meals and baking. They also discussed how service users access transport facilities to attend day centres and other activities. Staff spoken with were very knowledgeable in regard to the support plans, service users needs and the support they require. They gave examples as to how they ensure service users rights and choices are maintained. One service user spoken with said, “staff are very helpful and I can make my own choices.” One service user spoken with said that staff were very nice and looked after them well and listened to them. Staff were observed to interact well with the service user at home and maintain professional relationships. Service users have the opportunity to discuss the menu at the monthly meetings and suggest meals they would like, staff confirmed that this takes place and that these meals are incorporated into the menu. They also said that service users go shopping with staff and choose their meals this way. Records of the menu and the meals taken were kept; the menu on offer remains wholesome and appealing. There was evidence that service users also have take-a-ways on occasion. One service user spoken with said that meals were very nice and plentiful. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal care in the way that suits their individual needs and preferences. Service users are protected by the homes medication policies and procedures; however further development of the self-medication risk assessment would be beneficial to clearly outline how this is managed. EVIDENCE: Support plans for personal care were extremely personalised and reflected service users personal needs, likes and dislikes. One service user spoken with said, “I generally look after myself, but staff are here to help me if I need them.” Staff spoken with were able to discuss the level of support service users need and the concept on ensuring that independence is maintained. There was evidence within service user case notes to demonstrate that they have contact with the doctor, optician, dietician and other specialist services as required. One service user was seen to leave the home with a member of staff to attend an out patients appointment. Staff spoken with discussed the level of support offered to service users in these instances. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 15 Medication checked on the day of the visit corresponded with the prescription. Medication received into the building was signed for and all unused medication returned to the pharmacy. Demonstrating that service users had received medication as prescribed all administrations had been signed for appropriately. Two service users case tracked self administer medication, there was a plan of care in place for this and a signed declaration, however further information on the risk assessment such as where the medication is stored and how administration is managed and monitored discreetly was not fully in place, however the manager did discuss the procedure in place. One service user spoken with discussed the medication arrangements they have in place and stated they were happy with this. Staff spoken with confirmed that they had undertaken relevant training including training in administering medication in an emergency when a service user may experience an epileptic seizure. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel that they can talk with staff and express any concerns they may have and that these will be dealt with. Service users are protected from abuse. EVIDENCE: The complaints procedure is displayed in the home to ensure that service users and visitors have access to this. The information provided prior to the visit stated that there have been no complaints received since the previous inspection and the manager confirmed this. The service user spoken with said, “I can talk to the staff at any time, the manager listens to me and sorts things out.” Staff spoken with discussed how they would handle a complaint should it be received. During service users monthly meetings there is also the opportunity to air any grievances with staff and fellow residents, minutes of this taking place was seen. Further training in adult protection has been undertaken by staff to ensure that correct policies and procedures are followed, thus further protecting service users. Staff spoken with were able to discuss how they would act in the event of suspecting that abuse was occurring and how they de-escalated potential untoward incidents. There have been three reported incidents since the previous inspection, all of these had been dealt with appropriately and resolved. Service users have support plans in place specifying when the registered provider is the appointee and what the arrangements are for safeguarding Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 17 service users finances and enabling individuals’ to access their own money. Social Services are the appointee for some service users. Records of service users finances are now kept in the home. One service user spoken with discussed how they handle their finances and the support they get from staff. The home’s policy and procedure for management of residents’ finances was updated in August of this year to reflect the support that service users are given with their finances. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained, comfortable and homely environment. EVIDENCE: A maintenance person is employed who carries out routine maintenance to ensure service users live in a well-maintained and comfortable environment. Furnishings are of a domestic nature and the décor in the communal areas remain pleasant and calming. In addition to the main lounge and dining room there is a quiet room, which residents can access and another small lounge where time can be spent with friends and family in private. One service user spoken with said, “the home is always tidy and I have brought many of my own things in to make my room more special.” A housekeeper is employed to ensure the home remains clean, pleasant and hygienic; all areas seen were clean and tidy. Following appropriate assessments service users also are involved in domestic duties and keeping their room clean and tidy. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Ensure systems are in place to ensure all staff files contain the required documentation to ensure service users are fully protected. Provide further evidence fully substantiate staff training undertaken, ensuring certificate are available and any in-house training is recorded on individuals files. EVIDENCE: To ensure all new staff are aware of their roles, responsibilities and service users needs, they undergo an induction. This involves two weeks working closely with another member of staff and undertaking a course with an outside agency. The course covers the majority of compulsory training such as manual handling, fire and health and safety. One member of staff on duty on the day of the visit had just completed their induction. The information provided by the manager prior to the visit confirmed that this process is undertaken. One member of staff has attained the National Vocational Qualification (a nationally recognised work and theory based qualification) level 3, one has attained level 2 and two are working towards level 2. Staff spoken with confirmed that had undertaken this award. The information provided prior to Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 20 the visit corresponded with this information gained and the manager discussed how in the future all new staff would be encouraged to undertake this training. Working towards ensuring service users are protected by the home recruitment policies and procedures the manager said that all new staff have a satisfactory POVA 1st (a check to see if an individual has been placed on a register when they have been identified as abusing a vulnerable person) and/or a Criminal Record Bureau check (a police check to see if an individual has a caution or criminal conviction) in place prior to commencing employment. Once these have been returned if necessary they are discussed with the prospective staff member and their employment decided upon. Four staff personnel files were seen, all contained criminal record bureau checks. Three files did not contain proof of identity; these were longer term members of staff and the manager said that he would deal with this issue, also one file where the staff member had been employed for a long time there were no references in place, this was discussed with the manager who will prepare a character reference for them. Further records of training is now available within a hardback book, this showed that staff are completing compulsory training as required and the manager confirmed that this had taken place. On observing staff personal files, there was evidence within them that staff were undertaking training, however not all had certificate in place to correspond with the records on the file. Staff spoken with said that training was at a good standard and they felt supported by the management in pursuing any training they felt they needed. There was evidence in a supervision record of a staff member asking for further training and this being provided; the staff member concerned confirmed this. There was evidence of staff undertaking training in epilepsy thus complying with the requirement set at the previous visit and ensuring staff feel competent in supporting service users with this condition. All staff now receive regular supervision sessions where they are able to discuss their training and development. There was evidence of these being undertaken in staff personnel files and staff spoken with confirmed that these take place. . Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a manager who is open, approachable and dedicated to ensuring service users live a fulfilling and quality life. Service users are encouraged and enabled to have a say in how the home is run. EVIDENCE: The manager is registered with the Commission for Social Care Inspection. He has completed the National Vocational Qualification level 4 and has also completed a management qualification in the past. He discussed how he ensures that he works closely with staff and service users to ensure that high standards of care are maintained. Staff spoken with confirmed this takes place and stated that he was always approachable. One service user spoken with said that the manager is very nice, they could always talk with him and he always does things for them. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 22 Further developments have taken place with regard to monitoring quality assurance. Service users monthly meeting minutes and staff meeting minutes are still available which demonstrate that quality issues are discussed. In addition to this questionnaires have been sent out to relatives, the responses were all of a very positive nature such as; “the home is in constant touch with me, it is excellent, I am completely satisfied with the standards of care,” “everyone is treated like a family member, staff are always caring and very good” and “the service combines the interests of individuals and offers affection and stimulation.” The manager has not as yet sent these to service users, however following discussion this will now take place in the near future. Although there are no other records to demonstrate that quality assurance monitoring is taking place the manager works closely with staff and service users and he stated that he is continually monitoring the service and addressing issues as required. All incidents occurring in the home are now reported to the Commission for Social Care Inspection as required thus enabling appropriate monitoring of the service. The information provided prior to the visit shows that regular servicing and maintaince continues, such as electrical appliance testing, hoist equipment and fire detection equipment. Staff have received training in health and safety and first aid to enable them to deal with emergencies should they occur. Relevant policies and procedures are in place for maintaining health safety and welfare of service users, there is no policy in place for when staff may face aggressive behaviour, however staff were clearly able to discuss how they would deal with challenging behaviour if this occurred. The manager said he would consider implementing a policy to ensure that management remains according to the expected policy. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X X 3 Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(4,c) Requirement Further develop risk assessments for those service users who self-administer medication to ensure they are fully supported and protected. Timescale for action 30/10/07 2 YA34 19 schedule 2 30/11/07 3 YA35 18 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 25 1 YA39 Continue to develop and record quality assurance monitoring that takes place thus reflecting that service users views and opinions are fully considered. Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Loreto Cottage Care Home DS0000008713.V350773.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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