Inspection on 07/09/06 for Loretta House

This inspection was carried out on 7th September 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 14 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 04/01/06

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 Donna Ahern Unannounced Inspection 7 September 2006 11:30 th Loretta House DS0000065681.V304309.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 Loretta House DS0000065681.V304309.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. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Loretta House Address 4 Hunton Hill Erdington Birmingham West Midlands B23 7NA 0121 384 5123 F/P 0121 384 5123 lhome@btinternet.com 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 Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 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. 4th January 2006 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 accommodations 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.V304309.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit was unannounced involved one inspector and took place over a day lasting five and a half hours. This was the homes first key inspection for the inspection year 2006-2007. During the visit the inspector met with all ten residents to observe the opportunities and support provided to them, to look at the premises, and to read records about care, staffing, and health and safety. Time was spent with the registered manager and discussions took place with two support staff. A pre-inspection questionnaire was not completed by the manager and returned to CSCI prior to the fieldwork visit. The home is required to report incidents, accidents and other events that occur in the home to CSCI. These are called regulation 37 notifications. All information reported via a regulation 37 notifications since the last inspection was analysed prior to the fieldwork visit. What the service does well: What has improved since the last inspection? The acting manager left in March 2006 and the deputy manager has been in the acting managers position since. There is evidence of steady progress on previous requirements. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 6 There is evidence of ongoing work to people individual plans and Health Action Plans so that all residents have the required information in place some further development is required. Progress had been made on ensuring all residents including the people who require a lot of staff support are enabled to go out and enjoy opportunities in the community. Further progress has been made on supporting residents to be more involved in developing independent skills within the home. One residents said “ We are doing more things in the house now I even did some ironing which I am really pleased about I like doing things for myself ”. What they could do better: One of the residents who needs have changed requires a reassessment by Social Care and Health. Further development of risk assessments is required so that it is clear what help, support and guidance they need from staff so that they can do things safely. The manager and staff need to explore how residents are more involved in their individual service user plan. One residents said “I have never seen my care plan I know I should be able to read it if I want to”. Risk assessments and guidelines required implementing for the use of a residents wheelchair so that they are supported safely and their wheelchair is kept in good working order. How residents are supported with moving and handling needs more information so they get the right support from staff. It would be good practice if the complaints procedure was available in alternative formats to meet the needs of residents, for example pictorial and audiotape, as not all residents are able to read. Training in epilepsy is required so that staff have the knowledge and skills to support residents. The Gas Safety check was required to ensure gas appliances in the home are safe, have been serviced as required and don’t put residents at risk. A general risk assessment for the premises was in place and it was advised that this was reviewed so that a safe environment is provided for residents and staff. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 7 There has not been a registered manager for a long time. There is an acting manager in place. An application to register a manager is required so that resident’s benefit from having a permanent manager who can continue to develop the home. 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.V304309.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 Loretta House DS0000065681.V304309.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective residents are provided with relevant information about the home to enable them to make an informed choice about if they want to live there EVIDENCE: Loretta House provides accommodation to ten residents who have a learning disability. The home is not suitable for a person who has a physical disability as there are steps and level changes on the ground floor, no lift and the bathroom has no aids or adaptations. A variation to the homes registration has been previously agreed for one named person over the age of 65. Another resident is aged over 65 and shortly two more residents will reach the age of 65. The provider will need to submit an application for a variation to its registration for these people. A copy of the persons care plan demonstrating the homes ability to continue to meet resident’s needs must support the application. One of the residents requires a reassessment by Social Care and Health and the provider must reply formally to CSCI demonstrating how they can continue to meet the person’s needs. The Statement of Purpose must be updated to include how the home continues to meet the needs of some of the residents who are aged over 65 years. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 10 The service user guide had been updated and was in a large print format with some pictures included. It was advised to further enhance the availability of this information to residents the documents could be provided on audiotape. The manager was keen to pursue this. An admission procedure has been developed and this 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. No residents 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.V304309.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Individual service user plans and risk assessments require further development so that they detail how resident’s needs are to be met. Residents must be supported to take part in the process. EVIDENCE: The home has a service user plan for each individual. Three plans were sampled. There is evidence of ongoing work to individual service user plans and further development is required. There should be evidence of goals and targets with outcomes that can be measured. One of the service user plans seen required updating to reflect the residents change in need and how this had impacted on the level of care and support now required from staff. Where appropriate the service user plan should cross reference to relevant risk assessments. The manager needs to explore how residents can be more involved in the care plan process. When asked one residents said “I have never seen my care plan I know I should be able to read it if I want to”. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 12 The previous inspection required risk assessments to be implemented. A format has been implemented however this consists of a list of risk, which have then been assessed for each individual. Some of the risks are not relevant for specific residents. Risk assessments should be implemented where there is a known or perceived risk for an individual. A risk assessment in place for a resident who travels independently included no information about the specific skills of the individual. Risk assessments implemented for the kitchen just focused on not using knives or a hot oven and again were not specific to the skills and ability of the individual. It was positive that a monthly report is completed for each person summarizing the person’s needs and health care. It was advised that this process could be developed so that it is more structured and could be used to keep the individual service user plan under review. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place so that people living in the home experience a meaningful lifestyle. EVIDENCE: Most residents attend day centres, some attend college and others attend social clubs and engage in activities such as line dancing, attending church, Special Olympics and shopping for toiletries. Most activities appeared to be established and part of the homes routine. One resident said she is involved in lots of activities and “I like to keep busy”. “I really enjoy the Special Olympics and have been to lots of different places”. In house activities are also arranged including a games evening which residents said they enjoy. The previous report raised concern about the opportunities for one resident to take part in activities in the community. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 14 The Manager said that the lack of community visits was due to this resident’s poor mobility and the fact that she did not have a wheelchair. It was positive that progress had been made. Tracking of the residents daily records indicated that she had been supported on a number of occasions to go out. Two other residents require a high level of staff support to engage in appropriate leisure activities in the community and the manager confirmed that specific arrangements are made so that they get the opportunity to go out and have the appropriate support from staff. Previous inspection reports have highlighted the need for residents to be more involved in developing independent skills within the home. The last report noted that progress had been made and further progress was evident at this fieldwork inspection. One residents said “ We are doing more things in the house now I even did some ironing which I am really pleased about, I like doing things for myself ”. Another resident said “Staff help me do some cooking I enjoy doing it but would like to do it more often but it depends what staff are on duty”. Sampling of records and discussion with staff indicates that residents are supported to maintain contact with relatives and friends. Some residents have visits from family or spend time at the homes of relatives. Six of the people had been on holiday to Blackpool and Great Yarmouth arranged by local clubs that they attend. Four people were preparing for a trip to Blackpool in September 2006 and will be supported by staff from the home. Residents were observed moving freely around the house. Some residents choose to spend time in their room on return from their daytime activity. Most residents relaxed in the front lounge chatting about their day and waiting on their evening meal. One resident mentioned that in the evening staff seemed to spend most of their time in the office or rear lounge where two residents prefer to spend their time. They felt that staff should also spend time in the front lounge and with some of the other residents. Residents 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.V304309.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The health needs of residents are generally met but progress towards completing health action plans is required. Risk assessments with moving and handling issues must be developed so that residents are not put at risk. EVIDENCE: Residents personal appearance was good and indicated that residents receive good support to attend to their personal care needs. They wore clothing appropriate to their age, culture and time of year. The manager has just commenced the implementation of health action plans; a health action plan is a plan of what a person needs to do to stay healthy. Resident’s files had details of visits to a range of professionals. Risk assessments and guidelines required implementing for the use of a residents wheelchair. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 16 These must specify the use of lapbelts/posture belts and when they are used and should also specify that the wheelchair be used in accordance with manufactures guidelines and serviced to ensure the safety of the person using the chair. Guidelines had been implemented for staff to follow for residents who had specific health needs such as diabetes. These should ensure that the resident receives prompt assistance from staff and ensure that staff know when to seek medical assistance. Regular weight checks are taking place and are a good indicator to potential health problems. Manual handling risk assessments required some further development so that they are clear and specific about the level of staff support so that residents moving and handling needs are met. As raised under core standards “choice of home” a reassessment of a resident is required due to their change in need so that the appropriate support, aids and equipment are provided. All staff had completed the care of medicines training. Satisfactory records of medication received and returned were available. Medication administration records (MAR) had been signed when medication had been administered. The observed practice is that staff completes their own medication record sheet. They copy the information provided by the pharmacist. It is advised that this practice is reviewed and the MAR charts from the pharmacy utilised to minimise the risk of any recording errors. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are listened to. The abuse policy requires some clarification so that residents are protected from abuse. Information about how to complain should be produced in a format that residents can understand and follow. EVIDENCE: The complaints procedure was 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. Residents spoken with were generally clear regarding whom to speak to in the event of needing to make a complaint. They said, “I can talk to my key worker or the manager”. It would be good practice if the procedure was available in alternative formats to meet the needs of residents, for example pictorial and audiotape, as not all residents are able to read. The previous inspection report highlighted that several comment cards received from relatives indicated that they were unsure of the home’s complaint procedure. The manager said that following the previous inspection a copy of the procedure was sent to all relatives. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 18 The multi-agency guidelines were on display in the home. A copy of the No Secrets document was not available and it was advised that a copy was obtained and shared with the staff team. The Vulnerable Persons policy was read and some clarification is required so that it is really clear that Social Care and Health are the lead agency in the event of an adult protection incident occurring. It must also make clear staff responsibility to pass on any information relating to a protection issue. 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). Resident’s financial records were not sampled at this inspection. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 19 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, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The standard of the environment within this home is generally high providing residents 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. Five of the residents showed the inspector their room. Bedrooms are individual and personal to the occupants, with personal possessions and effects in evidence. One resident had recently had their room decorated and said they were really pleased with how it now looked. There is a choice of lounge areas, one large lounge, and one small quiet area, which offers residents a choice. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 20 Décor throughout the home was observed to be in good order. There are no specialist adaptations to the house as at present, although grab rails are provided in two bathrooms. One resident has limited mobility and as raised previously in this inspection report it is required that a referral is made for a reassessment of their needs. There is specific concern about how the person accesses the bath and the potential risk to the resident and the staff who support them. 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. A recent Environmental Health Inspection by Birmingham City Council raised a couple of minor points including the painting of a storage shelf, which had been actioned. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 21 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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The staff team offer consistency of care and have a good understanding of residents needs. Residents are protected by the home’s recruitment practices. EVIDENCE: The home has a stable staff team, and some of the staff had worked with the residents for many years. Staff spoken to presented as enthusiastic and knowledgeable of residents needs. It was evident that some staff and residents had got to know each other very well. Interactions between staff and residents were positive, and the way residents were supported was sensitive and respectful. In general there are two staff on duty during the day, occasionally three. Staffing is provided on an adhoc basis to support residents to access the community, for instance shopping outings. At night there is one staff member who undertakes a waking night shift. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 22 The home does not employ a cook or a cleaner; staff on duty undertake these tasks in addition to their caring duties. It is strongly recommended that the home employs ancillary staff for cooking or cleaning. The home has a stable staff team which gives continuity of care. Currently all staff are female and there are three male residents. Consideration should be given to the appointment of male staff when recruiting so that residents have a choice of receiving personal support from staff of the same gender. The staff files of the two most recently employed staff were assessed. The records of staff recruitment contained all the required documents and ensure that residents benefit from appropriately recruited staff to protect them from harm. Records seen indicated that staff have received supervision on a regular basis. The content of supervision sessions was not examined. Staff spoken to during the fieldwork visit said they felt well supported by the manager. Staff files contained details of training courses undertaken. Fire Training had recently been provided and refresher training on Manual Handling and Adult Protection were being planned. It was positive that staff had undertaken some training in the specific needs of residents such as Diabetes and Makaton these must be added to the training matrix. Training in epilepsy is required so that staff have the knowledge and skills to support residents. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 23 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 in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Health and safety is generally well managed. Some matters requiring attention were identified. An application to register a manager is required so that resident’s benefit from having a permanent manager who can continue to develop the home. EVIDENCE: The home does not have a registered manager and this has been the case for some time. The home does have an acting manager but an application for registration has not yet been made. Fire tests and servicing had been undertaken as required. Records seen indicated that regular fire drills had been actioned at different times in the day. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 24 A drill undertaken in the evening had a poor response from residents and it was positive that the manager was addressing this. A work place fire risk assessment was in place and had been reviewed. The fire and electrical supply had been serviced and tested as required. Evidence of the Landlord Gas Safety check was required to ensure gas appliances in the home are safe have been serviced as required and don’t put residents at risk. A general risk assessment for the premises was in place and was due to be reviewed so that a safe environment is provided for residents and staff. Quality assurance systems have been implemented but were not fully assessed at this fieldwork visit. Visits and reporting required under Regulation 26 (Care Homes Regulations 2001) are carried out each month by the Owner and a copy of the report is sent to CSCI. Residents meetings are held monthly some further development of these were required so that there is evidence of what action has been taken on issues raised by residents. Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 25 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 2 2 2 3 2 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 2 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 3 3 X 2 X 3 X X 2 X Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4 Schedule 1 Regulation 4 (1) (c ) 13(1)(b) &23(2)(n) 14 (2) Requirement The Statement of Purpose must be updated to include how the home meets the needs of residents who are aged over 65 years. One of the residents requires a reassessment by Social Care and Health. Timescale for action 30/11/06 2 YA3 30/11/06 3 YA3 14 (2) The provider must reply formally to CSCI confirming how they can continue to meet the person’s needs. The provider will need to submit 30/11/06 an application for a variation to its registration in respect of specific residents. A copy of the persons care plan demonstrating the homes ability to continue to meet resident’s needs must support the application. Care plans require improvement to include detailed information on goals and aspirations and must be kept under review. The home must ensure residents are included in the 4 YA6 12(1)(a) & 15 30/11/06 Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 27 care planning process. 5 YA9 13(4) Risk assessment must be developed. Detail the hazard, level of risk, control measures in place and should cross reference to care plans. Risk assessments and guidelines required implementing for the use of a residents wheelchair. Manual handling risk assessments required some further development so that they are clear and specific about the level of staff support. The Adult Protection Policy required some further development. 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). Previous requirement. A referral must be made to ensure one resident has all the specialist equipment she needs. Previous requirement 28/02/06. Training in epilepsy is required so that staff have the knowledge and skills to support residents. An application to register a manager is required Evidence of the Landlord Gas Safety check was required. The general risk assessment for the environment required review. 31/10/06 6 7 YA18 YA18 13 (4) 13 (5) 30/09/06 30/09/06 8 9 YA23 YA23 13 (6) 12(1) &13(6,7,8) 30/11/06 30/11/06 10 YA29 13(1)(b) &23(2)(n) 18 (1) c 30/09/06 11 YA35 31/12/06 12 13 14 YA37 YA42 YA42 8 (a) (b) 23 13 23 13 (2) b.c (4) (2) b, c (4) 30/11/06 30/09/06 30/09/06 Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 28 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. Refer to Standard YA1 Good Practice Recommendations Service user guide. Consideration should be given to including photographs of the home, and the use of video or audiocassette to enable residents who are not able to read to have their own copy in a usable format. An alternative format for the written menu should be developed for residents 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. It was advised that the monthly report process could be developed so that it is more structured and could be used to keep the individual service user plan under review. Staff completes their own medication record sheet. They copy the information provided by the pharmacist. It is advised that this practice is reviewed and the MAR charts from the pharmacy utilised to minimise the risk of any recording errors. 2. YA17 3. 4 YA33 YA6 5 YA19 Loretta House DS0000065681.V304309.R01.S.doc Version 5.2 Page 29 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.V304309.R01.S.doc Version 5.2 Page 30 - 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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