Inspection on 13/01/09 for Lorraines Residential Home

This inspection was carried out on 13th January 2009.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lorraines Residential Home 07/07/09

Lorraines Residential Home 24/09/08

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Lorraines Residential Home 44 School Street Church Gresley Swadlincote Derbyshire DE11 9QZ Lead Inspector Claire Williams Unannounced Inspection 13th January 2009 09:00 X10015.doc Version 1.40 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 Lorraines Residential Home DS0000071736.V373795.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 Older People. 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. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lorraines Residential Home Address 44 School Street Church Gresley Swadlincote Derbyshire DE11 9QZ 0115 942 5840 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 Parvin Riaz Khan Mr Inam Rehman, Mrs Abida Parveen Ashraf Vacant Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 17 24th September 2008 2. Date of last inspection Brief Description of the Service: Lorraines is a care home registered to provide personal care and accommodation for up to 17 people in the category of older persons. The service is an existing, which has had new providers who have been successful in registering with us. Lorraines Care Home is located in the small village of Church Gresley, South Derbyshire and is 1 mile from Swadlincote. Lorraines Care Home has a front garden and a patio area, and a car park. Lorraines has 9 single rooms, and 4 double rooms. A variety of lounge and dining room space is provided. Information about the service is provided through the Statement of Purpose and Service User Guide, it is one document that is made available to people who live in this service. People have access to the inspection report which is referred displayed in the corridor. The fees for the home are £355 to £364 per week. Items not covered in the fees include hairdressing, chiropody, toiletries, and transport. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is zero star. This means the people who use the service experience Poor quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of 2 days. This is the second Key inspection visit to this service this year. Following our previous inspection we found that the service was providing poor outcomes for people. This visit was undertaken to monitor and ensure improvements had been made to the service provided to people. In order to prepare for this visit we looked at all of the information that we have received since our last visit which was undertaken on 24/09/08. This includes: Notifications and information received from the service about events that have occurred. We also used the improvement plan we received as evidence of the improvements the provider said they would make. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of two people representing a cross section of the care needs of individuals within the service. Discussions were held with those individuals as able, together with a number of others about the care and services the home provides. Their care planning, and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their deployment, recruitment, induction, training and supervision, and records examined to support the procedures in place. What the service does well: People told us they liked living at this service. They said they liked their bedrooms, which they have personalised with their own personal possessions. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 6 People spoke positively about the staff and the following comments were made: “The staff work hard and try their best” “I feel like I am looked after well, and the staff are caring”. “The staff team treat me well; we have some good girls here”. “The staff team never rush me and are very friendly and gentle”. People told they were happy with the environment, which they said was homely. What has improved since the last inspection? What they could do better: The departure of the manager has resulted in the deterioration of the systems in place for the daily running of this service. This includes record keeping, communication processes, medication practices, and support provided to the staff team. It also has resulted in many of the requirements not being addressed and this was the manager’s responsibility. The service has not had a manager since 23rd December and a deputy has not been in place since September 2008, therefore the staff have not had any leadership or direction on how to respond to situations. We have made 14 requirements as a result of this inspection. The areas that require improvements include the following; Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 7 For people to be assessed before they move into the service so that their needs can be assessed and the person assured this service is able to meet these needs. The medication recording, handling, safekeeping, administration and disposal, needs to be improved so that people receive their medication as prescribed by their GP and in a safe manner by trained and competent staff. For people to be consulted about the provision of activities. This is to ensure there social needs’ are recorded and met by the service. For the staff team to have refresher training in safeguarding vulnerable adults so they can respond appropriately and confidently in safeguarding situations. Reviews to be ongoing to ensure the staffing levels in place are sufficient to meet people’s needs including social needs. Sufficient staff should be on duty to supervise people at all times. All new staff need to be recruited appropriately to ensure all information is obtained before they start work. This will ensure people are safeguarded from harm For staff to access formal supervision and regular team meetings. This is to ensure they are supported in their role and aid communication within the service. A system needs to be implemented to seek people’s feedback about the service they receive. This is to ensure the service provided is meeting their needs. For systems and training to be in place to ensure the health and safety of the staff and people living in this service is promoted and safeguarded. For a manager to be recruited in order to manage the service in peoples best interest and to provide support and direction to the staff team. We have made 22 good practice recommendations which cover a variety of areas. If addressed and responded these will improve outcomes for people who use this service. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 8 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. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 1, and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective people are provided with the information they need to know about the service. However pre –admission assessments are not undertaken to ensure the service can meet individual’s needs. EVIDENCE: People continue to be provided with information about the service and the facilities available. This ensures people have clear information about their rights and what to expect from this service. The manager has left this service, therefore no manager is currently. There has been one admission since our last visit. This person was not assessed before their admission due to living outside of the area. A Care manager’s assessment was not in place in this person’s file at the time of our visit. However an assessment of this person’s needs was undertaken on their admission, which provided staff with information about how to support their needs. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 11 The provider and deputy manager are now aware they must confirm in writing to state if they can meet peoples needs’ following the pre-admission assessment or after people have completed a trial visit living at this service. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 7, 8, 9, and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People’s needs were accounted for and met, although medication shortfalls may place people at potential risk. EVIDENCE: We looked at two files and both of these did contain person centred care plans that covered all of the peoples needs. They reflected people’s preference, which should ensure people receive individualised care that meets their expectations. This is an improvement from our findings on our previous visit. Each care plan that we sampled contained the required risk assessments that should be undertaken to monitor people’s mobility, pressure areas, nutrition and falls. This is an improvement from our last visit. There was evidence in the files to support they are reviewed on a monthly basis. However there was no evidence in files to support that a formal annual review had been undertaken. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 13 Discussions we held with people and the care records that we looked at told us that their healthcare needs were met. All people spoken to told us they receive support which is provided in a safe, respectful and dignified manner, and our observations supported this. We spoke to some relatives who told us they thought the care provided was good. On our arrival we observed that some medication was not stored securely, and was located in a room accessible to people living in the service. Once identified the medication was moved into a secure area. The staff member responsible for administering the medication told us that they had not received training in this area, and did not feel confident or competent to undertake these tasks. In response to this the staff rotas were changed to ensure senior staff members administer the medication. A notice was displayed to state that training had been arranged for the following week, to be delivered by the supplying pharmacy. We checked the storage for controlled drugs and this was satisfactory. When we looked at the medication records we identified many shortfalls with the recording practices. Some of these included; changes made to the prescribed medication instructions, and medication being administered more frequently then what was prescribed. There was no rational recorded on the chart or in peoples care plan to explain the reasons for this practice. Medication that people was prescribed to take for short intervals of time such as antibiotics were not being signed for in sequence with the dates on the medication chart. This has the potential to confuse staff and place people at risk. An audit of the medication practices has not been implemented in order to monitor the standards in place. Some of these shortfalls were addressed at the time of our visit; the storage of medication was made secure, and the Medication Administration sheets were re-written to ensure they contained clear instructions and correlated with the dates medication was to be administered. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 12- 15 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. People do not have access to opportunities to meet their recreational or social needs and expectations. EVIDENCE: On the day of our visit we observed that no activities were planned or provided to people in the service. We made a requirement following our last visit about this, and there was no evidence to support that there has been any improvement in this area. It was stated on the improvement plan that the manager was responsible for implementing an activities programme, which was to be displayed. However there was no evidence to support that this was achieved before she resigned. Due to the implications of this, the timescale will be extended for this requirement to be addressed. This will give the provider an opportunity to consult people and make suitable arrangements for recreational activities to be provided and a programme devised. During our discussions with people they told us they are bored and have nothing to do. These are the comments that we received on our last visit. People told us they do have papers delivered and that they organise their own Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 15 activities. Relatives spoken to also said they were disappointed in the lack of activities as they said “there used to be a good provision of activities before”. There has been some improvement in the information provided in the care plans, which now include people’s preferences and likes/dislikes, in respect of activities. People told us they were satisfied with the food provided. The menus in place still reflect that only one choice is available, but there is a separate sheet that reflects the alternatives. Observations of the lunch time meal, confirmed that alternatives to the main option was provided. The catering staff do not have access to information about people’s dietary preferences or like and dislikes. However as the staff have worked at this service for a few years they told us they knew peoples preferences and any dietary requirements. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to enable people to make complaints, and to safeguard them from abuse, but staff have not received training to ensure they work in accordance with these procedures. EVIDENCE: People spoken to told us they knew how to complain and they said they would not hesitate to raise any issues with the staff team. A complaint book is now in place, and the procedure is displayed. The service has received one complaint since our last visit and this was in relation to a person’s room being cold due to problems with the heating. There was evidence in the book that this issue had been responded to and we were told the heating problem had been addressed. During our last visit a copy of the Multi-agency Safeguarding adult’s procedures could not be located, and this was the case on this visit. Contact was made to Social Services following our visit and we received confirmation that a copy of the procedures was in the post. These procedures should be in the service so that the staff are aware of the local protocols to follow. Internal procedures are still in place to provide guidance. We issued a requirement for the manager and staff to attend safeguarding adults training due to issues we identified with the way a safeguarding incident was responded to. The improvement plan stated that the manager was going to arrange this. However there was no evidence to support any action had been taken. The provider had organised a meeting with a representative from Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 17 a local college and we received evidence to support that a training request has been submitted for all staff to attend training in this area. We did speak with staff about what action they would take if they had suspicions or witnessed any practices of abuse. All staff members were able to describe an understanding of their responsibilities in reporting these. The service or CSCI have not received any safeguarding issues since our last visit. We were told that training for staff about the Mental Capacity Act, had not yet been arranged. This is essential training for staff to enable them to be aware of this legislation and how to promote and enable people to make decisions about their lives. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the environment was well maintained, not all areas were safe which has the potential place people at risk. EVIDENCE: During our last visit we did not identify any issues with the building and standards were good and the building was safe and well maintained. During this visit when we undertook a tour of the building we identified several hazards. These included: • • • • Storage units located in the bathroom areas, which contained toiletries that were not labelled. A can of Air freshener left in a communal area. Floor mats that had been folded up, after they had been washed, which curled up in the middle presenting a trip hazard. Laundry door wedged open. DS0000071736.V373795.R01.S.doc Version 5.2 Page 19 Lorraines Residential Home • Items of clothing and items located in the bathroom area. Once identified these hazards were addressed, and removed and the building was made safe for people to move about in. We received comments from people and their relatives who told us the domestic standards have deteriorated especially at weekends. The duty rota indicated that the domestic staff members only worked in the week and therefore there was no domestic support was available during weekends. We discussed this with the registered provider who agreed to look into this matter. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 27 - 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are not supported by a trained staff team who have been recruited to ensure they are safeguarded from risks. EVIDENCE: When we arrived at the service there were two staff members on duty. Both of these were care assistants and one of these staff members had commenced employment a month before. As previously stated the most experienced care assistant had to undertake medication tasks although she has not received any formal training. This staff member works part time and therefore was unaware that she was due to work with a new staff member, administer medication and she did not know that a new person had been admitted to the service. This lack of communication and poor planning of the rotas has the potential to place people at risk. We issued a requirement previously about the staffing levels and requested for these to be reviewed based on the dependency of the people living in the service. The improvement plan indicated that additional staff would be recruited and the staffing levels increased at peak times. The rotas for the weeks prior to our visit supported that this action was taken. However we were told that the staffing levels were reduced again as some staff members had stated that an additional staff member was not required. Observations during our visit indicated that the staffing levels were not in accordance with the dependency needs of the people living in the service. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 21 People were left unsupervised for periods of time as the two staff, were supporting one person. During this time individuals who had a level of confusion were wondering in and out of other peoples rooms, and opening the Fire emergency door, which has the potential to place them, at risk. The registered provider (who was on duty and supported us with the inspection), reviewed the staff rotas and amended these to ensure an additional staff member was on duty during peak times of activity. This action was to be effective from that evening, but due to a staff member phoning in sick, and no cover being available it was due to commence the following day. The staff we spoke to during our visit told us that they did not feel supported in their role and did not feel the service was being managed effectively due their being no manager in place. They told us the communication processes were poor and the morale was low due to recent changes and events that have occurred in the service. The new staff member told us that she had shadowed a few shifts but then she worked as part of the team. She said she was given the induction book to look through by the manager before she resigned. However she has been provided with any support to go through this, and said she did not know what to do with it. This was her first time working in this role and she had not undertaken any mandatory training to date. We looked at the files of the two recently employed staff for evidence of the procedure that had been followed for their recruitment. Both were recruited by the manager before she left. We identified the following shortfalls; a full employment history had not been requested or obtained for one of the staff members, one file contained only one reference. Both files did not contain proof of identity. Both files contained evidence that a Pova first check had been completed before they commenced employment which is an improvement following our last visit. However we issued a requirement following our last visit that all required information should be obtained before staff commence employment; therefore this has not been addressed. Due to these matters being the responsibility of the manager who has since left, we have carried forward this requirement. The registered provider started addressing the shortfalls with the recruitment practices during our visit. We were told that a training programme is not in place, at the moment, but the provider has arranged to meet with a college delegate, to arrange for all mandatory and service specific training, to be delivered. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 31, 33, and 35. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The Health, safety and welfare of people is not always promoted and protected in this service. EVIDENCE: As we have stated within this report the manager has left the service, and a replacement is not yet in place. This has had an impact on the way this service is managed and on outcomes for people living in this service, due to the lack of leadership and direction for the staff team. Although one of the registered persons for this service has started working at the home, they do not have the skills or qualifications for this role. During the period of our visit, one of the senior members of staff was promoted to a deputy position. She is now supporting the provider to manage Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 23 the service. There was evidence to support that the manager’s position has been advertised and some enquiries have been made in relation to this position. There has been some improvements made in addressing the previous requirements but some are still outstanding as no action has been taken. Due to the current situation we will extend the timescales to enable the registered providers and deputy to address the outstanding shortfalls. The improvement plan that we received told us the following had been achieved; audits had been implemented to monitor standards, a system was in place for supervision and quality assurance systems have been devised. However when we asked for evidence of these no records or systems were in place. Staff spoken to also told us they had not yet had any supervision. There was evidence to support that 7 staff have undertaken moving and handling training but 11 staff members still require this training. Staff have completed Fire training and a Fire risk assessment is now in place. However when we checked the Fire records, there was no evidence to support that any Fire checks had been completed since October 2008. This places people and the staff at significant risk of harm and is a breech of the legislation. Once we identified these shortfalls, arrangements was made that day to check the call points and to implement a system for the ongoing monitoring and maintenance of all of the fire systems. There was evidence to support that all electrical appliances had been Pat tested to ensure they were safe for use in July 2008. At the times of the visit the Gas and electrical certificates could not be located. However following our visit we received evidence of the electrician’s certificate and a new certificate was obtained for the gas. There was evidence to support that one staff meeting had been undertaken and a further one planned in order to discus the current management arrangements in place. There are systems in place for looking after people’s money and when checked these were found to be satisfactory. People told us they can access their money when they choose to. Information provided on the improvement plan indicated that the manager from another service would undertake monthly visits to the service in order to monitor the standards in place. There was evidence of the reports that had been completed. One of the registered persons is currently working as the service as the capacity of the manager and therefore is aware of the current situation and shortfalls. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 2 X 1 Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14 (1) Requirement People must not be admitted to the service until a pre-admission assessment had been completed and obtained. This is to ensure the service is able to meet the person assessed needs. Medicines must be given in line with prescribed instructions. This must be demonstrated by record-keeping practices To ensure that people are protected and receive their medication as prescribed. All staff who administer medicines must be trained and competent to undertake this role. To ensure the safety of people in the home A system must be implemented to monitor and audit the medication records and practices. This is to ensure people receive their medication as prescribed. (Requirement extended to enable the provider and deputy to address ) Medicines must be kept in secure cupboards that are used solely DS0000071736.V373795.R01.S.doc Timescale for action 27/02/09 2. OP9 13.2 01/02/09 3. OP9 13.2 01/02/09 4. OP9 13.2 20/02/09 5. OP9 13.2 01/02/09 Page 26 Lorraines Residential Home Version 5.2 6. OP12 16 7. OP18 13 8. OP27 18 9. OP29 19 10. OP30 18 11. OP31 8 for the storage of medicines. To ensure the safety of people in the home and to prevent theft or misuse (2) (n) Residents must be consulted about a programme of activities. This is to ensure their recreational and social needs are met by the service. (Requirement extended to enable the provider and deputy to address ) (7) Arrangements by training or by other measures must be taken, to ensure the staff are fully aware of their responsibilities under the local safeguarding multi-agency procedures (Requirement extended to enable the provider and deputy to address ) (1) (a) The staffing levels must be kept under review to ensure they meet the dependency levels of people living in the service. This is to ensure sufficient staffing levels are available at all times to meet resident’s needs. (1) (b) All of the required legal recruitment checks must be undertaken on new employees before they commence work in the service. This is to ensure residents are safeguarded from any risks. (Requirement extended to enable the provider and deputy to address ) ( c ) (i) All staff must attend training to ensure they can fulfil their roles and responsibilities. This is to ensure people’s needs are met to a good standard. Arrangements must be made to appoint a manager in this service to ensure the service is managed in accordance with the standards and in the best interest of people DS0000071736.V373795.R01.S.doc 31/03/09 31/03/09 31/03/09 01/02/09 31/03/09 31/03/09 Lorraines Residential Home Version 5.2 Page 27 12 OP33 24 13 OP36 18 (2) 14. OP38 13 (4) that live here. A system for reviewing the quality of care provided must be implemented. This is to ensure that residents are regularly consulted about the service they receive. (Requirement extended to enable the provider and deputy to address ) A system must be put in place to ensure all staff have access to formal supervision. This is to ensure they receive appropriate support. (Requirement extended to enable the provider and deputy to address) The health and safety of the service must be monitored and records completed to ensure it is a safe place for people to live and work. 01/03/09 31/03/09 01/02/09 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. 2. 3. 4. 5. Refer to Standard OP1 OP2 OP4 OP7 OP7 Good Practice Recommendations The statement of purpose and service user guide should be updated to reflect the current management arrangements in this service. The assessment of need should be reviewed to incorporate the following areas of diversity: race, gender identity, disability, sexual orientation, age, religion and belief. A copy of the letter confirming that the home can meet a persons needs should be kept in peoples file. A key worker should be implemented so that each resident has named staff member they can refer to. Each person should have a formal review of their care undertaken on an annual basis to ensure all information is current. There family and representatives should be DS0000071736.V373795.R01.S.doc Version 5.2 Page 28 Lorraines Residential Home 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. OP9 OP9 OP9 OP9 OP9 OP9 OP12 OP13 OP15 OP18 OP26 OP27 OP29 OP30 OP30 OP30 22. 23 OP33 OP33 invited to this review. Handwritten medication instructions should be countersigned by two people in order to validate the instructions. When codes are used on the medication record, an explanation should be recorded to explain the reason why the medication was not administered. Medication should be checked upon arrival and the records completed to reflect this. The staff members that administer medication should have a re-assessment of their practice to ensure it is safe and in accordance with the policies and procedures. The current edition of the British National Formulary (BNF), or similar book on medicines, should be available for staff reference. A medicine policy describing current practice in the home should be available for staff reference. The policy should be dated, and a future date for review should be set. Information about residents preferred social activities should be recorded in their file and be part of their social care plan. Residents should be consulted about accessing the office telephone for personal calls. The menus should reflect the choices available. Residents should be regularly consulted about the food provided and records kept. A copy of the local multi-agency safeguarding procedures should be obtained and followed. The domestic hours currently in place should be reviewed to ensure the service is clean at all times. The staff roster should contain staff member’s full names and roles. The staff recruitment files should be audited to ensure they contain all of the required information to meet the current legislation and standards. A staff training programme should be developed and include training in relation to dementia care to assist them in their role. Staff should access training in mental capacity act so they are aware of people’s rights to make decisions. A training and development plan should be completed on each staff member and placed on their training file so that it is clear when they have attended training and what is planned for the future. A system for audits should be implemented to monitor the standards in the service. Staff members should have supervision six times a year. DS0000071736.V373795.R01.S.doc Version 5.2 Page 29 Lorraines Residential Home 24 OP38 They should also have an annual appraisal and access to regular team meetings. Footplates should be attached to wheelchairs, unless the residents request otherwise. Evidence should be available in resident’s files to support the reasons for this. Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lorraines Residential Home DS0000071736.V373795.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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