Inspection on 07/07/09 for Lorraines Residential Home

This inspection was carried out on 7th July 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lorraines Residential Home 13/01/09

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 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Lorraines Residential Home 44 School Street Church Gresley Swadlincote Derbyshire DE11 9QZ Lead Inspector Claire Williams Key Unannounced Inspection 7th & 8th July 2009 09:00 DS0000071736.V376416.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Lorraines Residential Home DS0000071736.V376416.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 Manager post 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.V376416.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 15th April 2009 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. 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 displayed in the corridor. The current fees for the service are £365 to £375 per week. Items not covered in the fees include hairdressing, chiropody, toiletries, and transport. Lorraines Residential Home DS0000071736.V376416.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 stars. This means the people who use the service experience Poor quality outcomes The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people who use the service and their views of the service provided. This process considers the services capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Following a key inspection on the 13th and 14th Jan 2009 we found that the service was providing poor outcomes for people. We completed a random inspection on 15th April 2009, in order to monitor compliance with the requirements we made, and to ensure improvements had been made to the service provided to people. We found further shortfalls at this visit and we sent a warning letter and immediate requirement letter. We also made requirements in the random inspection report. We have now completed a key inspection which was unannounced and lasted for a period of two days. The purpose of this visit was to monitor the service provided to people and assess the progress made to improve outcomes to people who live in this service. We were supported on this visit by an expert by experience. An expert by experience is a person, who, because of their shared experience of using services, and / or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. In order to prepare for this visit we looked at all of the information that we have received since our last visit. This may include notifications from the provider, surveys, and complaints or concerns. We also used the improvement plan we received following both the previous key and random inspection. We did not receive the pre-inspection annual quality assurance questionnaire, which the provider is required to complete, until after our visit. We have included evidence from this document within the body of our report. Prior. This assessment gives the provider an opportunity to let us know about their service and how well they think they are performing. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of three people representing a cross section of the care needs of individuals within the service. The expert spoke with these individuals as able, together with a number of others about the care and services the home provides. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 6 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 are encouraged to visit the service in order to meet the staff and people that live here, and to enable them to make a decision about their future. People told us they are “happy” with the care provided. Visitors told us they are welcomed into the service, and they were “satisfied” with the care provided. What has improved since the last inspection? What they could do better: Each person who lives in this service must have a detailed, person centred care plan. This is to ensure the staff have access to information to direct and guide them on how to deliver care and support. Each person must have risk assessments completed in areas such as mobility, pressure area care, falls and nutrition. This is to ensure any risks are identified. A plan of care must then be implemented to monitor and reduce these risks. The staff need to ensure they keep all medication stored securely, so people are not at risk. They need to ensure systems are in place to ensure people receive their medication as prescribed. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 7 The staff team need to have refresher training so they can respond appropriately and confidently to safeguarding situations, and to ensure they are trained in all mandatory areas in order to fulfil their roles. A review must be undertaken 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. Risks assessments need to be undertaken of the environment to ensure the building is a safe place for people to live. We have made some good practice recommendations which cover a variety of areas. If addressed and responded these will improve outcomes for people who use this service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 8 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.V376416.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National minimum standards 1, 2, 3 and 5. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed to ensure this service is able to meet their needs. However not everyone is provided with the required information to enable them to be aware of their rights when moving into this service. EVIDENCE: In the self assessment the provider told us they care and ensure people’s needs are met. They provide friendly staff who welcome people and their relatives into the service. People told us they have a copy of the service user’s guide, which tells them what facilitates and services they can expect. This document also informs them of their rights whilst living in this service. We were told this document is currently being reviewed so it reflects the current management arrangements. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 10 People we spoke to and feedback in the surveys confirmed that individuals are encouraged to visit the service in order to familiarise themselves with the routines and to meet the staff and people. One person told us “I came for respite to check the home out, and now I have decided to remain here as it meets my needs and I like it here”. We looked at the records for three people who had recently moved into the service. All individuals had been assessed by the service or by their respective Care managers, and contracts were in place for those people whose care was being funded. However a contract had not been provided for the person who was self funding. This means this person has not been formally told about the fees payable and their rights and obligations when living in this service. Letters confirming that the service was able to meet people’s needs had not been sent to these individuals in order to formally assure them that their needs can be met. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National minimum standards 7, 8, 9 and 10. People using the service experience Poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although people’s needs are met, they are not clearly set out in a written plan of care, and the medication practices have the potential to place people at risk. EVIDENCE: In the self assessment the provider told us they monitor people’s needs and act accordingly if there have been any changes. They told us they assist people in the required areas and promote peoples independence. We looked at three peoples care more closely and looked at their care files, to ensure their needs were clearly recorded. Each file we looked at contained some information about peoples needs, but not all of the person’s needs were covered. This means staff do not have access to written information, to guide and direct them on how each person would like to supported. People told us there needs are met, and the staff told us they are able to meet peoples needs Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 12 based on the verbal information provided, and the pre-admission assessments in place. Each care plan that we sampled did not contain all of the required risk assessments that should be undertaken to monitor peoples mobility, pressure areas, nutrition and falls. We found blank copies in the files or these records were missing. This means areas of risk had not been assessed and identified in order to guide staff on how to support and monitor people’s health care needs. There was evidence to support that contact with external health care services is routinely made, and people spoken to confirmed this. We looked at two files for people who have lived in the service for a period of time. We found that their plan of care was in place and it was reviewed on a monthly basis. However there was no evidence to support that formal reviews are completed on an annual basis, to ensure all documentation is reviewed and to confirm the placement is meeting people’s needs. The expert by experience spoke with people and to visitors who were present in the service. People told him they were satisfied with the standard of care provided. The visitors spoken to said “I am content with the service and the care of my relative”. All of the people we spoke to told us they receive support which is provided in a safe, respectful and dignified manner, and our observations, supported this. On our arrival to the service we observed that medication had been dispensed into 3 medication pots, and left in a communal area, unsupervised. This medication had been signed on the records as administered, which is unsafe practice. When this issue was identified this medication was made secure, however this practice places people at risk, as all medication must be secure at all times. We looked at the medication records for five people, and the records had been completed satisfactory for four people. However one person’s medication that was administered only when they needed it, had run out. Although there is an audit system in place for the monitoring of the meditation, this issue was not identified so that a new supply could be re-ordered. This resulted in the person not having access to their medication for a period of four days, which made the person anxious during this time. The records supported that some senior staff have received accredited medication training, which included a practice observation. Further training is being arranged for those staff members that require this training. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National minimum standards 12 to 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although people now have access to some activities, this provision does not meet all peoples expectations and preferences. EVIDENCE: The provider told us in the self assessment they try and ensure people are happy. They have identified and told us they could improve the provisions of activities they provide to people. People told us some improvements have been made to providing recreational activities. A member of the staff team has now been allocated 8 hours for providing this provision. People told us they had been on an outing a few weeks before our visit to a summer fete, which they said they had enjoyed. People told us they are supported to play bingo each week and the hairdresser continues to visit on a weekly basis. We did not observe any activities taking place during the time of our visit. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 14 Records had been completed of the activities undertaken in people’s files. Some individuals told us they have received one to one support to go to the shop or for a walk, and they said “it was really nice to get out and have some fresh air”. A programme of activities is not in place; therefore people do not know what activities are planned for each week. People told us “it would be nice to have some information and have activities every week”. We were told this is something the activities staff member is working towards. We did see a notice displayed, requesting volunteers to facilitate a trip to the park which was being planned for a few weeks time. People told us they were able to choose how they wished to spend their day, and if this resulted in them remaining in their room, this decision was respected. People said they have daily newspapers delivered or collected if they wanted them, and some individuals were observed reading these. People told us their visitors are able to visit whenever they wanted to, and the visitor’s we spoke to told us “we are always welcomed into the service”. We spoke to people about the food provided and individuals told the expert that some improvements had been made but “the standards can still be improved.” A menu was displayed which reflected choices and alternatives for each day. People told us they had enjoyed the meal they were served during our visit, and they hoped “the quality would get better”. We visited the kitchen and spoke with the catering staff who were able to show us records of peoples dietary requirements. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National minimum standards 16 and 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of 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 formal training to ensure they work in accordance with these procedures. EVIDENCE: The provider told us in the self assessment they have a complaints procedure in place and they address any issues raised. During our discussions with people they told us they knew how to complain and they said they would not hesitate to raise any issues with the staff team or manager. The feedback provided in the surveys also confirmed that people was aware of how to raise any concerns. People told us they have access to the complaints procedure in the information they have been provided with previously, and the procedures is displayed. However the procedure is out of date and needs reviewing so it reflects the new contact details for Care Quality Commission and to include the details of other external contacts that people can access. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 16 The service has received 3 complaints since our last visit, and all issues related to the quality of the food being provided. As stated in the previous outcome area, improvements have been made in response to the issues raised. The staff we spoke to demonstrated a general awareness of both the complaints procedure and their role and responsibilities concerned with dealing with any potential abusive incidents. The staff team have not yet received formal training in safeguarding adults, but a date has now been planned for September. The service has not had any safeguarding incidents since our last visit, and we have not had any issues referred to us. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National minimum standards 19 and 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although people live in an environment that’s meet their needs, not all areas are safe for people to access. EVIDENCE: The provider told us in the self assessment they provide a clean and tidy environment with good decoration and adequate fixtures and fittings. They said they try to make it as homely as possible. We undertook a brief tour of the building and can confirm the information in the assessment. We found all areas to be clean, comfortable, homely, warm and well lit. All areas were furnished and decorated to a satisfactory standard. We did note that the windows on the first floor did not have restrictors fitted and a risk assessment was not in place. As a person uses a room on this floor Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 18 an assessment needs to be undertaken to ensure this area is safe for them to access. People confirmed they are encouraged to personalise their bedrooms and those visited reflected peoples preferences. People told us the building suited their needs, and they confirmed they had access to equipment which encouraged and promoted their independence. People have access to a smoking area which is located outside and is fitted with a roof for access in all weather conditions. People were observed using this area, during our visit. The garden area would benefit from being tidied and made secure as a fence panel is broken which leads onto a neighbour’s garden. Most people access the service by using the rear entrance, which has a small step by the door. A sign is not in place to make people aware of this potential trip hazard and a risk assessment has not been completed. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National minimum standards 27 to 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by a trained staff team, but they are not available in sufficient numbers to ensure peoples needs are met at all times. EVIDENCE: The provider told us in the self assessment they try to ensure that sufficient staff are on duty at busy times. They said they are in the process of developing a training programme. On our arrival there were two senior care staff, a domestic and a cook on duty. There is no manager currently working in this service, therefore the senior staff were supporting people with daily tasks, in addition to trying to answer the telephone. Discussions with people and the staff team indicated that the staffing levels are not sufficient, based on the dependency needs of the people currently living in this service. A person who had recently moved into the service for short term care requires two people for all their support. This means that people are left unsupervised for periods of time when the two staff, are supporting this one person. During this time individuals who had a level of confusion were wondering around the service unsupervised, and people had to wait for support. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 20 There has been an increase in the number of people who have moved into this service for short and long term care since our last visit. There was no evidence to support that the staffing levels had been reviewed (as the provider had indicated in the self assessment) in accordance with the needs of the new people, who had moved into the service. People told us “The staff don’t seem to have any time for us” “The staff are always rushing about and the phone is ringing, it’s really busy here”. “The staff work really hard, but there just isn’t enough of them”. “The staff team do a good job, they support me well, but they are often rushed” We were told that 8 of the staff have completed a National Vocational Qualification to level 2, which ensures staff have the skills and knowledge to support people. We were told that service specific and mandatory training has now been sourced for the staff to attend. This has been a shortfall identified on our previous visits, as a staff training programme is not in place. We received evidence to support that training had been planned in relation to Dementia, and medication, for those staff that have not completed training in these areas. There have been improvements made since our last visit to the way staff are recruited to work in this service. We looked at two staff member’s recruitment files. Both contained all of the required recruitment information, to demonstrate that all of the checks had been undertaken to ensure these individuals were suitable for their role. We were also provided with information to support that an induction is in place for all new staff to complete. This will enable them to gain the required skills and knowledge for their role. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National minimum standards 31, 33, 35, and 38 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is not managed in people’s best interest. EVIDENCE: The provider told us in the self assessment they have implemented the strategies enforced by the consultant who has been working in the service due to the absence of a manager. They told us they are currently trying to recruit and appoint a suitable and competent manager to run the service. The acting manager, who was present at our last visit, has now left the service. The providers arranged for a management consultant to work in the Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 22 service until a new manager was recruited. On our arrival we were told the consultant no longer worked in the service on a daily basis. We had not formally been advised of this, and were unaware that a named person was not in charge of the daily running of the service, in the absence of the providers. As a consequence of this the service has not been managed in accordance with the legislation or in people’s best interests, as there is a lack of leadership direction, and support for staff. This has resulted in shortfalls to the care planning documentation, medication practices, training and the monitoring of health and safety practices. For example: People have been admitted into the service, without additional staff being on duty to support their admission and complete the required paperwork. The records demonstrated that the fire alarms have not been checked on a regular basis as required by law to ensure they are in safe working order. The domestic staff do not have access to the required information in order to work safely with the cleaning materials that are now provided in the service. A new manager has been recruited but the providers are in the process of completing all of the required employment checks. As an interim measure the providers have appointed a new deputy who will oversee the daily running of the service, with support from the providers until the manager starts employment. This will ensure people and staff have a named person who they can speak to for advice, and guidance. There was evidence to demonstrate that staff have received formal supervision which had been facilitated by the management consultant. We were told the providers would now continue with this process, until the new manager commences in her role. As mentioned previously a staff training programme is not in place. Although some training has been arranged, the staff team, still require refresher training in First aid, Moving and handling, food hygiene and infection control. Fire training has been arranged, but there was no evidence to support that the night staff receive this training twice a year as required. People told us they could access their finances when they wanted, and they were happy with the systems in place. When we checked the way people’s money was managed we found it to be satisfactory. We were informed that surveys have recently been sent out to people and their families in order to obtain their feedback. Some of these had been returned and the provider told us a report would be completed of the findings. A delegate of the provider undertakes monthly visits and completes a report of their findings in order to assess the service and the standards provided. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 2 3 n/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 N/a DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 3 x 3 2 x 2 Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP2 Regulation 5 Requirement People must be provided with a contract detailing the fees payable, upon their admission to this service. This is to ensure they are clear about what the costs are for living in this service. Each person must have a detailed care plan which covers all of their holistic needs completed upon their admission to the service. This plan must be developed in consultation with individuals and be kept under review. The plan must include reference to the individual’s ability to make decisions under the requirements of the mental capacity Act. This is to ensure staff have the information to meet peoples needs in a person centred way. People must have risk assessments completed in order to assess and minimise any potential risks to their health. This is to ensure people receive Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 25 Timescale for action 01/09/09 2. OP7 15 01/08/09 3. OP8 Schedule 3 01/08/09 4. OP9 13.2 appropriate support and intervention. All medication must be kept secure at all times. This is to ensure people are not placed at risk. People must receive their medication as prescribed. This is to ensure people receive their medication as planned. A risk assessment of the environment must be undertaken and include the risks associated with, the step at the rear entrance door, and of the first floor windows. Action must be taken to minimise any risks identified. 01/08/09 5. OP9 13.2 01/08/09 6. OP19 12 (3) 01/09/09 7. OP27 18 (1) (a) This is to ensure people live in a safe building. You must be able to demonstrate 01/08/09 that the staffing levels are sufficient to meet the assessed needs of people that use the service. This is to ensure sufficient staffing levels are available at all times to meet people’s needs. A risk assessment must be undertaken or training provided to ensure sufficient staff are on duty that are trained in First Aid. You must follow the actions outlined in your Fire risk assessment, to ensure people live in a safe environment. Training in Moving and handling must be arranged for the 5 staff who have not completed this. This is to ensure staff work in a safe way. 8. OP38 13 (4) 01/10/09 9. OP38 23 (4) 01/09/09 10. OP38 13 (5) 01/09/09 Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 26 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 OP1 Good Practice Recommendations The statement of purpose and service user guide should be distributed to all people living in the service after it has been updated to reflect the current management arrangements. 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 letter confirming that the home can meet a persons needs should be sent to all people that are assessed for this service. Each person should have a formal review of their care undertaken on an annual basis to ensure all information is current. Their family and representatives should be invited to this review. A system should be in place to monitor people’s weight. A medicine policy describing current practice in the home should be available for staff for reference. The policy should be dated, and a future date for review should be set. People should be consulted about a programme of activities, to ensure these meet their expectations. People should be regularly consulted about the food and the menu provided to ensure it meets their preferences. All staff who work in this service should access training in relation to safeguarding adults from abuse. The fence panel in the garden should be replaced to secure this area. A maintenance book should be in place to record any repairs that are required and the timescale for when these were addressed. The staff recruitment files should be audited to ensure they contain all of the required information to meet the current legislation and standards. Staff should access training in mental capacity act and deprivation of human rights so they are aware of people’s rights to make decisions. A training and development plan should be completed on DS0000071736.V376416.R01.S.doc Version 5.2 Page 27 2. 3. 4. OP2 OP4 OP7 5. 6. OP8 OP9 7. 8. 9. 10. 11. 12. 13. 14. OP12 OP15 OP18 OP19 OP19 OP29 OP30 OP30 Lorraines Residential Home 15. 16 OP38 OP38 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. Coshh sheets should be in place for the cleaning products being used in the service. The night staff should receive fire training twice a year Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Lorraines Residential Home DS0000071736.V376416.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!