Inspection on 30/01/07 for Loreto Cottage Care Home

This inspection was carried out on 30th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Loreto Cottage Care Home 26/09/07

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 Joanna Carrington Key Unannounced Inspection 30th January 2007 10:00 Loreto Cottage Care Home DS0000008713.V320654.R02.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.V320654.R02.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.V320654.R02.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 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.V320654.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category LD Date of last inspection 4th October 2005 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 fees for care and accommodation at the home are £307 per week. Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven hours on 30th January 2007. This was the home’s key inspection for this inspection year. The main method of inspection was called ‘case tracking’ which meant selecting three residents and tracking the quality of their care by checking records, discussion with them and with staff and observation of care practices. Altogether, two residents and two staff members were spoken with during the course of the inspection. Staff records were looked at to make sure staff get the training they need and checks are carried out on staff before they commence their employment. A partial tour of the premises also took place in order to assess environmental standards. Information obtained prior to the inspection, mainly in the preinspection questionnaire has also been used to inform judgements about the service. The registered manager was available for discussion and feedback throughout the majority of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 6 The safety and protection of residents is not adequately safeguarded in the home for a number of reasons: Recruitment checks are not being carried out before new staff members commence employment. There must also be better evidence that when a staff member has previous convictions that the necessary questions have been asked in deciding whether that person is fit to work in the home. This is an outstanding requirement from the previous inspection. Risk assessments are not being used in accompaniment to care plans in order to identify measures that will promote residents’ safety and also their independence. This is an outstanding requirement from the previous inspection. When residents have some challenging behaviour then in order to ensure that staff can manage this consistently and in an appropriate and respectful manner, detailed and specific care plans are essential. This may also help in reducing incidents as mentioned below. This is an outstanding requirement from the previous inspection. There are a high number of violent incidents between residents, with no evidence that any action is being taken to reduce these incidents. The Adult Abuse procedures are not being followed and Social Services are not being notified. Residents reported as if it is the norm that at times staff shout at them. This is not at any time acceptable and does not uphold residents right to dignity and respect. When sound monitors are used then it must be identified in a relevant care plan explaining why it is needed and when. This will ensure that residents’ right to privacy is respected. It cannot be guaranteed that the needs and welfare of residents are being adequately met if staff members are not getting the necessary training and support. Staff that have not worked in care and have not worked with adults with a learning disability before must have intensive and structured induction training to enable them to carry out their role. This should be Learning Disability Award Framework training. Staff should not be expected to carry out specialised techniques such as giving emergency medication for epilepsy if they have not had the required training. This is dangerous. There is no evidence in the home to indicate residents and their relatives / representatives have been issued with an up to date contract with the home, which states the cost of fees and how these are being paid. People are entitled to know this information, and also have some protection regarding terms and conditions of their placement. This is an outstanding requirement from the previous inspection. The quality of the service is not being effectively monitored, which does not ensure that the home is being well run or in the best interest of residents. Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 7 There must be systems put in place for reviewing the quality of care and procedures in the home and monthly monitoring visits must be part of this. 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 be made available in other formats on request. Loreto Cottage Care Home DS0000008713.V320654.R02.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.V320654.R02.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): 2 and 5 Quality in this outcome area is adequate. Residents / representatives have still not been issued terms and conditions of the home, which does not safeguard their rights and responsibilities. Residents had their needs assessed before moving to the home, which ensured that the home was suitable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection there was an outstanding requirement to ensure that in addition to the Social Services contract all residents are issued with a Contract / Terms and Conditions with the home. There was evidence seen at this inspection that a contract has been devised but there was no sign on the files of the residents’ case tracked that this document has been issued and signed. Residents and/or their representatives must be fully aware of the cost of fees for the placement and how these fees are paid for. All of the residents have lived at the home for a very long time. The residents’ that were case tracked have care plans in place initially written as far back as 1993. There was evidence of Community Care Reviews carried out by the placing authority, but these are from 2005 or before and do not constitute a full assessment of these residents needs. (Please see outcome area on Needs and Choices) Loreto Cottage Care Home DS0000008713.V320654.R02.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): 6, 7 and 9 Quality in this outcome area is poor. Care planning arrangements need improving, to ensure that the needs and choices of residents are being appropriately met. Risks continue not being managed properly, which neither protects the safety of residents nor promotes their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three residents case tracked have care plans in place that cover all aspects of their health, personal and social care needs. The problem is that the initial and most detailed part of the care plan is written as far back as 1993 then any amendments are recorded along the way. This makes it difficult to get an overview of an individual’s needs because some parts of the initial care plan will no longer be relevant. Some care plans have not been altered for a long time. When a care plan has been reviewed all that has been recorded is “reviewed” which is signed and dated. This is not adequate information. Another problem with the presentation of care plans was identified at the last inspection. There were no specific care plans for managing challenging behaviour, but this information is included under other headings. No progress Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 11 was seen with this requirement except for one resident that has been having input from a multi-disciplinary team. A specific care plan is now in place for this resident, which was devised by the multi-disciplinary team for the staff to use. Given the high number of abusive incidents that occur in the home (please refer to the outcome area Complaints and Protection) it is essential that specific care plans be developed for all residents with this particular need. This is to ensure they are supported consistently and ethically, and will help to protect all residents. A staff member spoken with mentioned how a resident that was case tracked is susceptible to being pinched and kicked by another resident. There is no protection plan / risk assessment in place that identifies strategies in order to prevent this resident being subjected to this abuse. This is also required to help ensure residents are protected. Risk assessments are still not being used in accompaniment to care plans. On a care plan seen there is reference to the resident “needing close monitoring when walking around on own so that doesn’t trip up” but there is no risk assessment for mobility and falls. A staff member spoken with was asked about the needs of a resident that was case tracked. The staff member mentioned that the resident is at risk of having seizures in the bath, but on their file there is no information / risk assessment in place for this. When a resident was asked if they can make their own decisions and choices the resident said that they have to be in pyjamas by 10.30pm or their friend is not allowed to visit. When asked, the registered manager clarified the situation, explaining this is not the case but there are arrangements in place, in order to manage certain risks. None of this is documented however, which is required in order to safeguard this resident’s rights and to take into account their wishes. Loreto Cottage Care Home DS0000008713.V320654.R02.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 adequate. Resident’s quality of life is promoted within and outside the home. The rights of residents could be better addressed. Residents enjoy wholesome nutritious meals but there could be more variation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection most residents were out either at day centre or at college. Some residents have work and voluntary placements. In the evenings there are also clubs run such as the Gateway Club that residents can choose to go to. Residents spoken with said they enjoy going down the pub on Fridays with staff to play pool. The activities book shows that recently residents have been to the cinema, out on the bus, watching DVDs and trips to the nearby country parks. Residents are supported to go to church every Sunday if they choose to. Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 13 Records seen also indicate that residents have frequent visits from family and friends. Residents spoken with said they often go home to see family at weekends. Developing daily living skills is encouraged, with residents regularly undertaking household tasks such as wiping tables, vacuuming and baking cakes. A record is kept of who has helped out in the activities book. Staff spoken with gave examples of how they maintain residents’ dignity and respect for example, always knocking on residents’ doors and helping people to do things they want to do. Both residents spoken with said staff treat them with respect but also mentioned there are times when staff have to shout and tell you off. Shouting and telling residents off is not good practice and does not promote and uphold residents’ dignity and rights. Residents spoken with said they liked the meals, especially fish and chip night. The menu records were examined and showed that on the whole the meals are wholesome and nutritious with a range of meat, fish and vegetable dishes. The staff must make sure that the meals are varied. The record showed that over one week baked beans had been served with the main meal four times and creamed potatoes three times. Loreto Cottage Care Home DS0000008713.V320654.R02.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 adequate. Residents receive personal support in the way they prefer and require. Some further improvements are required to ensure health is promoted and medicines are administered safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the care files seen there is detailed information on how to assist residents with personal care tasks washing and dressing and individuals’ preferences are also stated. There are records on the care plans seen stating when outside professionals have been involved in residents’ healthcare and when appropriate referrals have been made. For example, on a care plan for continence needs there is a record of when the district nurse came to assess and the outcomes. One of the resident’s case tracked visited the doctor to discuss deterioration in mobility and as a result was referred to hospital for an X-ray. The records seen still suggest that residents are not getting regular healthcare checks, which in line with the National Minimum Standards should be at least annually. One resident case tracked has not been to the dentist since July Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 15 2005 and residents spoken with could not recall when they last went to the opticians. Training for staff on conditions such as epilepsy is also essential in ensuring residents individual healthcare needs are met. (Refer to the outcome area Staffing in this report) The storage of medicines and administration records were audited and all appeared to be in order. Quantities of boxed medication are recorded on the medication administration record (MAR) and remaining quantities counted tallied with what has been signed as given. The instructions for administration of medicines and all entries on the record are clear. One of the residents’ case tracked has ‘as required’ medication for their epilepsy that is administered by specialised technique. There is no evidence on staff files that staff have been trained in giving this. This should be provided by a healthcare professional. Loreto Cottage Care Home DS0000008713.V320654.R02.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 poor Residents feel their concerns and complaints are listened to and acted on. Residents are not protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in the home. Both residents spoken with are aware of the complaints procedure, and confirmed they would raise their concern with the manager, and are confident that they would be listened to. The complaints file shows that there have been no complaints made since the last inspection. Incident records were examined at the beginning of the inspection and alarmingly showed a high number of violent incidents between residents. The registered manager was unfamiliar with the duty to inform Social Services of these incidents and to follow the local adult protection procedures. The Commission must also be notified so that the home can be regulated in its duty to protect residents. The registered manager was surprised this action would need to be taken every time there is an incident because there are so many. The registered manager reported that the staff team are attending training on abuse awareness next week. A letter was seen to evidence this. It is recommended that the registered manager make all staff aware of the home’s whistle-blowing procedure, to ensure they know allegations can be passed on to relevant outside agencies. A staff member spoken with was not aware of this. Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 17 Residents now have care plans in place specifying when the registered provider is the appointee and what the arrangements are for safeguarding residents’ finances and enabling individuals’ to access their own money. Social Services are the appointee for some residents. The handling of residents’ money could not be checked, as records are not held in the home. (Please refer to outcome area on Conduct and Management) Loreto Cottage Care Home DS0000008713.V320654.R02.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): Quality in this outcome area is good. Residents live in clean, comfortable and homely surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On a partial tour of the premises the environment appeared clean, fresh and there was a homely feel throughout. Furnishings are domestic in style and the décor is the communal areas of the home are 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. The bathroom décor is outdated but maintained to a satisfactory standard and serve their purpose. The bathrooms seen did not contain liquid soap, which is important for cleanliness and infection control. Some parts of the carpet are becoming worn. The manager reported that a new carpet was being fitted the following day. Loreto Cottage Care Home DS0000008713.V320654.R02.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, 35 and 36 Quality in this outcome area is poor. The staff team are not getting the training and support they require to meet the needs of residents. Recruitment practices are failing to protect residents, but instead placing them at serious risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is not enough evidence on the staff files selected to indicate all the necessary mandatory training and updates have been attended. There are no individual training records or assessments on staff files. General records that were seen indicate that not all staff have had the required health and safety training and staff spoken with confirmed this. One staff member spoken with has been working at the home for over a year and could only recollect having training on moving and handling. The registered manager commented that some training is carried out using videos and DVDs, but there is no record of this. It was seen on one staff member’s supervision notes that the staff member was upset at seeing a resident having a seizure. This identifies a need to learn about epilepsy but there is no evidence of any form of training been provided. The staff member was spoken with and confirmed this. The staff member also Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 20 pointed out in conversation that they do not work with the residents that are more disabled because the staff member does not feel they have the skills to do this. Again, this is a learning need that must be addressed in order to ensure residents benefit from an effective staff team. There is no evidence on the staff member’s file that they have had structured induction and foundation training. In line with the National Minimum Standards and the White Paper, Valuing People there is clearly a need for this training to be learning disability award framework (LDAF) training to provide underpinning knowledge for progress towards National Vocational Qualification (NVQ) level 2. The pre-inspection questionnaire states that only two staff members currently have NVQ level 2, which is way below fifty percent of the staff team having this qualification. The registered manager reported that the majority of the staff team are now doing it. The files of two staff members that have commenced employment since the last inspection were examined. One of these staff commenced their employment before the return of a POVA first check and there is no evidence on the file that they were supervised before the return of their criminal record bureau check. The criminal record bureau disclosure identifies serious convictions. There is insufficient evidence that the registered manager has addressed why these convictions were not declared on the application and the reason given for this appears to have been accepted without further exploration. The staff member has only had one supervision session since they commenced their employment, so their performance has not been adequately monitored in the light of this. Loreto Cottage Care Home DS0000008713.V320654.R02.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): 37, 39 and 42 Quality in this outcome area is poor. The lack of quality monitoring that seeks the views of service users does not ensure the home is well run and in their best interests. The health and safety of service users is promoted and protected. Notifying the Commission of incidents must improve to ensure the home can be effectively regulated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Except for monthly residents meetings the registered manager was unable to provide evidence of other ways that the quality of the service is monitored and reviewed. Questionnaires have not been sent out to residents and their relatives / representatives for a very long time and there has been no other internal audits on different aspects of the service provided. Monthly monitoring visits are also not being undertaken. This inspection has highlighted the need for improvements, which could have already been identified if systems for quality assurance were implemented. Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 22 The home’s policy and procedure for management of residents’ finances was seen and is not reflective of support that is given, so this must be updated. Residents’ financial records such as bank statements and transactions are not kept at the home. Copies of this information must be retained at the home in accordance with Care Home Regulations 2001. This was stated in the last inspection report. Daily records and incident records show a number of incidents which should been notified to the Commission in accordance with the Care Home Regulations 2001. The registered manager was informed of the Commission’s guidance on the website on what incidents must be notified. The pre-inspection questionnaire shows that gas and electrical systems are regularly serviced and there are adequate measures in place for the control of Legionella. The fire log seen during the inspection indicates that all necessary fire safety testing and drills are carried out as required. Loreto Cottage Care Home DS0000008713.V320654.R02.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 X 2 1 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 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 2 33 X 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 1 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 1 X 1 X 1 3 X Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 24 YES 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 YA5 Regulation 5(1)(c) Requirement Ensure that there is a standard form of contract for the provision of services and facilities by the registered provider to residents. This is an outstanding requirement, initial timescale 01/12/05 not met. Ensure care plans cover all aspects of need; this includes specific care plans on mental health and managing challenging behaviour, to ensure appropriate support is given and to protect residents. This is an outstanding requirement, initial timescale 01/12/05 not met. Ensure the needs of residents are regularly reviewed so that any changes in their needs and support are identified, and to confirm that the home remains suitable in meeting those needs. This is an outstanding requirement from the previous inspection, initial timescale 01/12/05 not met. Risks to residents must be properly assessed, to ensure their safety and welfare is DS0000008713.V320654.R02.S.doc Timescale for action 01/04/07 2. YA6 15 01/05/07 3. YA6 14, 15 01/06/07 4. YA9 13(4) 01/05/07 Loreto Cottage Care Home Version 5.2 Page 25 5. YA16 12(4) 6. YA20 13(2) 7. YA23 13 8. YA34 19 9. YA34 19 10. YA35 18 11. YA36 18 protected and also to identify restrictions on an individuals’ liberty. This is an outstanding requirement, initial timescale 01/12/05 not met. The home must be conducted in a manner that respects the dignity of residents at all times. The practice of shouting and telling off residents must stop. Ensure that staff members are trained in specialised / delegated interventions, such as giving emergency medication for an epileptic seizure. This is to ensure the safety of residents. Ensure Adult Abuse procedures are followed in the event of any form of abuse, which includes incidents between residents. Staff must not commence work in the home until appropriate POVA check and Criminal Records Bureau check has been undertaken. This is an outstanding requirement, initial timescale 30/05/05 not met. Make sure staff employed at the home are fit to work there. Where convictions are identified on criminal record bureau disclosures there must be sufficient evidence that this has been discussed with the staff member and that procedures have been followed in deciding to employ this staff member. Ensure all staff receive training that is essential in meeting the needs of residents. This includes all mandatory health and safety training, induction, national vocational qualification level 2 and other relevant courses such as epilepsy and disability awareness. Ensure staff members are DS0000008713.V320654.R02.S.doc 21/03/07 01/06/07 21/03/07 21/03/07 21/03/07 01/08/07 01/04/07 Page 26 Loreto Cottage Care Home Version 5.2 12. YA37 26(2) 13. YA39 24 14. YA41 37 15. YA41 17 appropriately supervised. This is to ensure the training and support needs of staff are monitored, and to ultimately ensure the welfare of residents. To ensure improvements are made and that the home is well run the registered provider must conduct monthly monitoring visits and submit a copy of each report to the Commission. Ensure there is a system in place for monitoring and reviewing the quality of care at regular intervals, which includes seeking the views of residents. Ensure that all incidents, as specified under this regulation, are made to the Commission without delay. This is so that the home can be effectively regulated. Ensure that residents’ financial records (or copies of) including bank statements, receipts and transactions, and evidence of financial audits, are kept in the care home. This is so that it can be regulated. 01/05/07 01/06/07 21/03/07 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 3. 4. Refer to Standard YA7 YA17 YA19 Good Practice Recommendations Ensure that arrangements agreed with residents on how they lead their lives are documented in relevant care plans and risk assessments. Offer more varied meals to residents. Residents are offered minimum annual health checks (including attention to vision and hearing; medication; illness/disability unrelated to primary disability/condition) and that these appointments are documented. DS0000008713.V320654.R02.S.doc Version 5.2 Page 27 Loreto Cottage Care Home 5. 6. 7. 8. YA23 YA23 YA35 YA36 Ensure all staff are aware of the whistle-blowing procedure. Update the Policy and Procedures for handling residents finances so that if reflects all support given. Liaise with Skills for Care over accessing LDAF courses as part of new staff members’ induction and foundation training. That formal and recorded supervision sessions take place at least six times per year. Loreto Cottage Care Home DS0000008713.V320654.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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