Inspection on 04/01/06 for Loretta House

This inspection was carried out on 4th January 2006.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Loretta House 25/07/07

Loretta House 07/09/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Loretta House 4 Hunton Hill Erdington Birmingham West Midlands B23 7NA Lead Inspector Kerry Coulter Announced Inspection 4th January 2006 10:30 Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 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 Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 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. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Loretta House Address 4 Hunton Hill Erdington Birmingham West Midlands B23 7NA 0121 384 5123 0121 384 5123 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) Kidderminster Care Ltd Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users shall be 10 persons with a learning disability, being adults under 65 years of age with one exception for an agreed named individual. Not withstanding Standard 25.5 iii, the provider will be required to clearly demonstrate how a positive choice has been derived from persons agreeing to share, their advocates and any funding body. Service users will be ambulant. Accommodation is not agreed for persons who have mobility difficulty beyond the physical limitations of the home neither for persons who are physically disabled. Appropriate locks are to be provided for service users rooms within 6 months of date of registration and existing dead locks are to be immediately taken out of use. 3rd June 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Loretta House is a large, traditional style, detached and extended property, located at the junction of Hunton Hill and the Birmingham Road. The homes location, provides good access to bus and train services at the Gravely Hill train station, a few minutes walk away. Loretta House provides accommodation to ten service users, all who have a learning disability. The home briefly comprises of, two lounges located on the ground floor, a dining area. An open plan kitchen and laundry. Bathing and toilet facilities are located on all floors. The home does not have a lift, and the ground floor is on different levels. Service users must therefore be able to negotiate stairs. There are no assisted bathing facilities in the home. There is a pretty well maintained private garden at the back of the house and off road parking for several cars to the front. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and was conducted by one Inspector over five hours. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from June 2005. This is however, the homes first inspection since a change of ownership in October 2005. At this inspection time was spent observing care practices, interactions and support from staff. Some of the service users have verbal communication difficulties and their ability to communicate to the Inspector their views of the home was limited. A tour of the home was made. Service user care plans, risk assessments and a number of Health and Safety records were inspected. Information was also supplied through the pre inspection questionnaire completed by the Manager and comment cards from service users, relatives and social care and health professionals. The Inspector had the opportunity to talk with one relative, members of staff, the Manager, Deputy Manager and new Owner. What the service does well: What has improved since the last inspection? Clear efforts have been made to meet the requirements made at the time of the last inspection. Prospective service users are provided with relevant information about the home to enable them to make an informed choice about if they want to live there. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 6 Staffing hours have been increased giving more flexibility to respond to service users needs. Recent initiatives instigated by the management team to include service user assessment tools and the introduction of monitoring for quality assurance demonstrate their commitment to developing the service for the benefit of the service users. Menus have been further developed to ensure service users are offered greater choice and variation of meals. Training has been provided for staff to ensure they can do their job and support people who live in the home safely. Since the last inspection additional in-house activities have been introduced to include cooking, music and art. Recruitment practice is satisfactory. Systems of staff support have improved with staff receiving regular formal supervision. 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. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 7 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 Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Prospective service users are provided with relevant information about the home to enable them to make an informed choice about if they want to live there. Documentation is now available to assist the Manager in ensuring appropriate assessment would be completed prior to a service user moving in. EVIDENCE: Requirements were made at the last inspection regarding the Statement of Purpose as it was missing some essential information. This document has now been updated to include the required information and also to detail the new owner of the home. The service user guide was also observed to have been updated and was in a large print format with some pictures included. The Manager said the guide would be explained to any service user unable to read. Consideration should be given to including photographs of the home, and the use of video or audio cassette to enable service users who are not able to read to have their own copy in a usable format. As previously required the home’s admission procedure has been expanded and is also detailed within the Statement of Purpose. A format has also been introduced to assist in the initial assessment of any prospective service user. The Manager and Owner explained this would be used alongside the social worker assessment and care plan. No service users have moved into the home since the last inspection and so it was not possible to case track the admission process in practice. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 9 New statements of the terms and conditions of the service users stay in the home have been introduced. Initial observation of the document indicates that it meets the required standard and includes information on fees and room to be occupied. One sampled document was observed to have been signed by the service user. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The care plans did not satisfactorily detail how the individual needs of the service users were to be met and were not person centred. Risks service users were taking were not assessed or planned placing service users at risk of harm. EVIDENCE: The home has a service user plan for each individual. Three plans were sampled. As identified at the last inspection information on the goals and aspirations were not included in the plan and plans for activities/ leisure and independent living skills such as cooking and laundry were not satisfactory in the files sampled. Care plans need to include specific details of the nature of support required for each individual, and exactly how that support should be delivered. Plans should set targets with outcomes that can be measured, and these should be evaluated at review. Whole care plan reviews should take place at least every six months, with written records maintained, indicating who takes part and how decisions are made. There is evidence of an active programme of review in the Home, and this should be commended but it was not evident if the service user had been part of the review. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 11 Further thought needs to be given to how the service user is included in the care planning process and how their participation is recorded on the plan. Everybody should be involved in writing their own care plan and have their own copy if they want one, written in a way they can understand it. This could be through using photographs and pictures or on audio- tape. Care planning systems are currently under review; the Manager and Owner are actively seeking ways to improve practice. One new introduction is a holistic assessment package of service users needs. Although not completed for all service users as yet the format appears useful and will eventually link into the care plans. Service user daily care records were of an adequate standard. Staff generally writes entries enabling the reader to track all the care provided. Records sampled and observation of practice indicates that choice is offered to include activities, meals, holidays and times of going to bed. People’s ability to exercise choice and to make informed decisions is variable, according to their degree of learning disability. Service users are encouraged to play an active role in what goes on in the Home, and this is facilitated through regular group meetings. There was no evidence of individual risk assessments having been completed for service users despite activities being undertaken that have some varying levels of risk to include service users going out without staff support and bathing unsupervised. Previous inspections have identified that risk assessments required development. The only progress made is that a format for risk assessments has been developed but these remain uncompleted. This is an area of planning and delivery that requires urgent attention to ensure service users, staff and others are safe. The new Owner assured the Inspector that the completion of risk assessments would be given a high priority. All confidential information pertaining to service users was seen to be securely held in the office. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 17 Arrangements are in place so that people living in the home experience a meaningful lifestyle. Opportunities for increased integration within the community need to be provided for more dependent service users. Meals are both well managed, and provide client choice. EVIDENCE: The last inspection identified that service users did not have adequate opportunities to develop independent living skills. Observation of records and discussions with staff and service users shows that progress has been made in this area. Records show that service users have increased opportunities to participate in activities such as shopping and other domestic tasks. One service user said that she now participated in assisting with cooking the evening meal once a week which she said she enjoyed. Most service users attend day centres, some attend college and others attend social clubs and engage in activities such as line dancing, attending church and shopping for toiletries. One service user spoke about how much she enjoyed working in a café once a week. Most activities appeared to be established and part of the homes routine. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 13 Since the last inspection additional in-house activities have been introduced to include music and art. All of the service user comment cards indicated that individuals were happy with the activities on offer. Most of the service users have adequate opportunities to participate in the local community but this was not the case for one service user who is more dependent on staff support. Tracking of her daily records over a two month period showed that apart from attendance at the day centre her only activity away from the home had been one visit for a meal out. The Manager said that the lack of community visits was due to this service users poor mobility and the fact that she did not have a wheelchair, however this was not reflected in the care plan. This area of the service requires urgent and significant work to ensure that the more dependent service users are enabled to undertake meaningful community activities, consistent with their peers. Sampling of records and discussion with staff indicates that clients are supported to maintain contact with relatives and friends. Some clients have visits from family or spend time at the homes of relatives. Comment cards received from relatives were generally positive in their opinions of the care provided. One example of a comment is that ‘staff are nice’. The area of meals and menu planning has improved since the last inspection. The home now has a four week rotating menu in place that shows a choice of food is on offer. This was in a written format, it is recommended that an alternative format is also used for service users who are not able to read. Service users spoken with said they were happy with the meals provided. Adequate stocks of food were observed to be available, this included supplies of fresh fruit. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Improvement is needed to ensure clients receive personal support in the way they prefer and require it. The health needs of service users are generally met but progress towards completing health action plans is not evident. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: Service users appeared to be well dressed, and to have been supported to wear clothes suited to the weather and temperature. Interactions between staff and service users were seen to be warm and friendly, and appropriately respectful. Support was offered sensitively and without undue haste. Further detail needs to be added regarding personal support to care plans to take into account the personal preferences of service users with regard to the gender of staff who support them. Service users health care needs are attended to, and records of appointments and outcomes are maintained in service users files. It was recommended previously that Health Action Plans should be implemented. This is something that the Government paper, ‘Valuing People’ said that each person with a learning disability should have by 2005. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 15 This is to ensure individuals receive all the care they need to stay healthy. The Manager must ensure these are now developed. The medication system in place was observed to be generally well managed. As previously required there are now clear written protocols in place to guide staff as to when any ‘as required’ medication should be administered. Satisfactory records of medication received and returned were available. Medication administration records (MAR) had been signed when medication had been administered. Certificates were available to show that staff have undertaken medication training. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users know that they can complain and that matters will be dealt with. General practice within the Home offers service users protection from abuse, neglect and self-harm but physical intervention policy requires further development. EVIDENCE: The home has a copy of the complaints procedure on display in the dining room and it is also available in the Statement of Purpose and Service User Guide. There have been no complaints received by the home or the CSCI since the last inspection. Service users spoken with were generally clear regarding whom to speak to in the event of needing to make a complaint. It would be good practice if the procedure is available in alternative formats to meet the needs of service users, for example pictorial and audiotape as not all service users are able to read. Staff could consult with service users to see if they would like to design their own poster about who and how they can complain and decide on where the posters should be. Several comment cards received from relatives indicated that they were unsure of the home’s complaint procedure, the Manager therefore needs to ensure relatives are made aware of the procedure. Major shortfalls were identified at the last inspection in regards to the home’s ability to safeguard service users from the risk of abuse. Much improvement has now taken place. Sampled staff recruitment records show that Criminal Record Bureau checks are undertaken and two written references obtained for staff. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 17 Previous inspections have identified that staff at the home have not received satisfactory training in the prevention of abuse and adult protection, this is still outstanding. Certificates are now available to show that staff have received the required training. The home has policies and procedures in place for adult protection, whistle blowing and physical intervention. The physical intervention policy is quite brief in content. It is required that the policy of physical intervention is further developed, in line with codes of professional practice to reflect guidance from the Department of Health and British Institute of Learning Disabilities (BILD). Service users financial records were not sampled at this inspection. However, as required at the last inspection a policy has been developed regarding contributions for service user meals away from the home. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29, 30 The standard of the environment within this home is generally high providing service users with an attractive and homely place to live. EVIDENCE: Loretta House is a large, old-style property located in a well-established residential neighbourhood. The house is in keeping with surrounding properties. It is evident that work has been done to maintain and improve the house, for the benefit of the people living in it. Bedrooms are individual and personal to the occupants, with personal possessions and effects in evidence. Communal areas have a distinct “lived-in” air. There is a choice of lounge areas, one large lounge, and one small quiet area, which offers service users a choice. Since the change of ownership of the home some new lighting and bedroom door locks have been installed. Décor throughout the home was observed to be in good order, but one male service user expressed dissatisfaction with the flowery wallpaper in his bedroom at the last inspection. The Manager said that following consultation with the service user repainting of his bedroom was now scheduled. The maintenance book for the home was sampled, this showed that any required repairs are carried out as required and without undue delay. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 19 There are no specialist adaptations to the house as at present no service users have been assessed as requiring them, although grab rails are provided in two bathroom. One service user has limited mobility. Discussion with the Manager indicates that this impacts on community access as she does not have her own wheelchair. It is required that a referral is made to an Occupational Therapist to ensure this service user has all the specialist equipment she needs. The home was observed to be clean and tidy throughout. The laundry is sited to ensure that soiled laundry is not carried through areas where food is eaten or stored. Appropriate infection control procedures are followed and hand washing facilities to include liquid soap and paper towels are provided. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The staff team offer consistency of care and have a good understanding of service user needs. Service users are protected by the home’s recruitment practices. Arrangements for supporting and developing staff are adequate. EVIDENCE: Support to clients is given in a warm and friendly manner, and staff were seen to be polite, considerate, patient and respectful, as appropriate. It is a strength of this home that many of the staff have worked at there for some time, service users are therefore supported by staff who know them well. Discussion with the Manager and sampling of records shows that at least 50 of the staff have achieved an NVQ or equivalent in care. Significant improvements have been made to staffing structures in the home since the home has changed owner. Staffing hours have been increased and one additional member of staff has been recruited. Discussions with the new Owner indicate that he hopes to further increase staff hours but this depends somewhat on the level of fees received. In general there are two staff on duty during the day, occasionally three. Staffing is provided on an adhoc basis to support service users to access the community, for instance shopping outings. The home does not employ a cook or a cleaner, staff on duty undertake these tasks in addition to their caring duties. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 21 It is strongly recommended that the home employs ancillary staff for cooking or cleaning. It was observed that the rota Monday to Friday showed handover time for the shift changeover of staff, this did not extend to the weekend. However immediate action was taken by the Manager to address this. Major shortfalls were identified at the last inspection with regard to recruitment practice. At this inspection the file of a newly recruited member of staff was observed to contain all the information as required by regulation. Previous inspections did not show that the staff team had received all the training they need to meet the needs of the service users. Discussions with the Manager and Owner at this inspection indicate a positive attitude towards training and development of the care team. Staff have now undertaken significant training to include Adult protection, fire, manual handling and diabetes. Makaton training had been arranged but the trainer was unable to attend and this is to be rescheduled. Several staff are due to attend Infection control and health and safety training. As required previously the Manager has now obtained certificates to evidence that staff have done food hygiene training. The supervision records for two members of staff were sampled. The home has adopted a formal structure for these supervisions sessions, and those examined provided evidence of a good support process for the staff. Staff meetings are held on a regular basis. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality assurance systems have been introduced and are generally satisfactory. The lack of risk assessments could compromise effective arrangements for promoting and protecting the health, safety and welfare of the service users. EVIDENCE: The home does not have a registered manager and this has been the case for some time. The home does have a manager but the application for registration is not complete. A requirement was made at the last inspection in regard to this but following a period of illness of the Manager an extension to the timescale given has been agreed. The last inspection did not evidence that key areas that are the responsibility of the manager had been fully addressed as required however significant improvements in standards have now taken place. Observation of the rota show that the new Owner is spending time in the home supporting the Manager in making the required improvements. Discussion with the Manager indicate that she has commenced an NVQ 4. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 23 Quality assurance systems have been implemented. Visits and reporting required under Regulation 26 (Care Homes Regulations 2001) are carried out each month by the Owner. A questionnaire has also been produced for completion by relatives, initial responses are generally positive although one relative would liked to see more activities on offer. Audits have been introduced to include service user files, accidents, incidents, staff records and the environment. Certificates evidenced that gas appliances had been serviced. The homes fire records were observed, these indicated that regular testing of the alarms and emergency lighting is carried out. Certificates of servicing were available for the fire alarms. Records evidence that a recent fire drill had been conducted. Records evidence that staff have received fire training in the last six months with further training scheduled for February. The home has risk assessments in place for the environment but the system of risk assessment for service users is inadequate and requires improvement, as detailed earlier in this report (Standard 9). Records showed that regular monitoring of temperatures of fridges, freezers and water are done. Temperatures were within safe levels. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 3 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 1 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 2 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Loretta House Score 2 2 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 3 X DS0000065681.V267906.R01.S.doc Version 5.0 Page 25 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 Regulation Requirement Care plans require improvement to include detailed information on activities/ leisure, communication development, independent living skills and goals and aspirations. The home must ensure service users are included in the care planning process. Outstanding requirement from 30/4/05. Timescale for action YA6 12(1)(a) & 15 28/03/06 2. YA9 13(4) Adequate risk assessments must be completed to underpin risks associated with the service users life style and activities. The risk assessment must detail the 28/02/06 hazard, level of risk, control measures in place and should cross reference to care plans. Outstanding requirement from 30/6/05. Ensure that the more dependent service users are enabled to undertake meaningful community activities, consistent with DS0000065681.V267906.R01.S.doc 3. YA13 16(2)(m) 28/02/06 Loretta House Version 5.0 Page 26 their peers. 4. YA18 12(4)(a)(b) Account needs to be taken of the personal preferences of service users with regard to the gender of staff who support them. In line with the Government’s white paper, ‘Valuing People’ each service user must have a health action plan. The Manager must ensure that relatives are provided with accessible information on the homes complaint procedures. It is required that the policy of physical intervention is further developed, in line with codes of professional practice to reflect guidance from the Department of Health and British Institute of Learning Disabilities (BILD). A referral must be made to an Occupational Therapist to ensure one service user (as discussed at inspection) has all the specialist equipment she needs. 28/02/06 5. YA19 6. YA22 22(5) 12(1)(a)& 15 30/03/06 28/02/06 7. YA23 12(1) &13(6,7,8) 30/03/06 8. YA29 13(1)(b) &23(2)(n) 28/02/06 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. YA1 Refer to Standard Good Practice Recommendations Service user guide. Consideration should be given to including photographs of the home, and the use of video or audio cassette to enable service users who are not able to read to have their own copy in a usable format. DS0000065681.V267906.R01.S.doc Version 5.0 Page 27 Loretta House 2. YA17 3. YA33 An alternative format for the written menu should be developed for service users who are not able to read. This could be actual photographs of the meals on offer. It is strongly recommended that the home employs ancillary staff for cooking or cleaning. Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 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 Loretta House DS0000065681.V267906.R01.S.doc Version 5.0 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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