CQC report explained · a residential care home
What the CQC found at Loretta House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People told inspectors they felt safe. Staff understood safeguarding and people's risks, medicines were recorded and stored safely, and there were enough staff who knew people well.
- Effective?
- Good
- People's needs were assessed and reviewed, and staff received induction, training and regular supervision. People were supported with food choices, healthcare, independence and relevant legal decisions.
- Caring?
- Good
- Inspectors saw staff treating people with kindness, dignity and respect. People were offered choices and encouraged to take part in daily activities and household tasks.
- Responsive?
- Good
- Care plans reflected people's preferences and were regularly reviewed. People had varied activities, community links and support to maintain relationships, although some documents were not yet available in an accessible format.
- Well-led?
- Requires improvement
- Management was approachable and people gave positive feedback, but governance systems did not reliably identify or correct problems. The provider had not updated its Statement of Purpose or notified CQC about a change in the type of person admitted.
What inspectors found, June 2020
Loretta House was rated Requires Improvement; inspectors found safe, kind and person-centred care, but weaknesses in management and quality checks.
This was an unannounced inspection on 7 January 2020. Two inspectors spoke with all six people living there, four staff members and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough trained staff, safe medicines arrangements, kind care, support for choice and independence, and activities suited to people's interests.
The overall rating was Requires Improvement because Well-led had fallen from Good at the previous inspection to Requires Improvement. Management checks did not always find problems, including incomplete cleaning records and weaknesses in recruitment records.
The provider had also failed to update its Statement of Purpose and tell CQC about a change in the type of person admitted. The report says people were not at risk of harm from this concern, but the provider was required to improve.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs. Medicines were managed, recorded and stored safely, and no agency staff were being used.
“People were supported by staff who knew them well, and no agency staff were used.” from the report
Kind and respectful care
Staff knew people well and treated them warmly. Inspectors saw people being supported with dignity, choice and independence.
“During our visit we observed people being treated with respect and dignity by staff.” from the report
Personalised activities
People had activity plans based on their interests and were supported to take part in community activities, education and daily choices.
“People had daily activity plans reflecting a wide range of choices and interests including knitting, flower arranging, cooking, dancing, listening to music and educational goals.” from the report
Good health support
Staff understood people's health needs and worked with healthcare and community professionals. People were supported to attend appointments and health checks.
“Staff worked well with a range of community professionals to ensure people's care needs were monitored and addressed.” from the report
Failure to update key information
seriousThe provider admitted someone whose needs differed from the other people living in the home. It did not update its Statement of Purpose or notify CQC about the change.
“The provider had failed to update their 'Statement of Purpose' and to notify CQC of the change.” from the report
Weak management checks
needs fixingQuality systems did not reliably identify problems. Cleaning records were incomplete, and audits had not picked this up.
“Audits of cleaning schedules had not identified that records of cleaning tasks were incomplete and furthermore, checks on audits had also not identified this.” from the report
Recruitment records were inconsistent
needs fixingSome staff files did not contain full employment histories, and information about references was not always clear. The provider said it would update the records.
“More robust practices around gaining employment histories and seeking and recording appropriate references was needed.” from the report
Some information was not accessible
needs fixingThe complaints policy and some care plans were not available in formats that people could access independently. The provider agreed that more work was needed.
“This included the complaints policy and care plans. We will review this at our next inspection.” from the report
- 01What has been done to make sure the Statement of Purpose is updated and CQC is notified when the people admitted have different needs?
- 02How are cleaning records and quality audits now checked so that missing records are identified promptly?
- 03Have all staff recruitment files been updated with full employment histories and clear reference details?
- 04How can residents access the complaints policy and their care plans in a format they understand?
- 05How will the home assess whether a new person's needs fit with the needs of the existing residents?
This was an unannounced inspection covering all five CQC questions; the previous Good ratings were from the inspection published on 27 July 2017, while Well-led fell to Requires Improvement. This explanation was written from the published report of 24 June 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2017
Loretta House is rated Good; inspectors found safe, kind and personalised care, with one past reporting shortfall.
This was an unannounced inspection on 13 June 2017. Inspectors spoke with six people living at the home, two relatives, two care staff and the registered manager. They also checked care records, medicines records, recruitment files, training and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine arrangements, suitable training, support with food and healthcare, and care that respected people's choices, privacy and independence.
The previous inspection in May 2015 found an issue with restrictions placed on people in their best interests. Inspectors found this had improved. They also noted one old incident had not been reported to the CQC promptly, although there was no injury or harm and the manager agreed to improve communication.
People felt safe
People and relatives told inspectors they felt safe. Staff understood safeguarding and knew how to respond to risks and emergencies.
“People told us they felt safe living at the home.” from the report
Safe medicines
Inspectors found medicines were given as prescribed and that storage, administration, recording and disposal were safe.
“All medicines received into the home were safely stored, administered, recorded and disposed of when no longer in use.” from the report
Kind and respectful care
Staff knew people well, listened to them and supported their privacy, dignity, choices and independence.
“People we spoke with all told us the staff were caring, helpful and kind.” from the report
Personalised support and activities
Care plans included people's preferences and interests. People were supported to take part in hobbies, social activities and individual plans.
“Care plans showed people's preferences and interests had been identified and were regularly reviewed taking into account individual needs.” from the report
Improvement since the last inspection
The home had improved how it protected people's rights when restrictions were used in their best interests.
“At this inspection we found there had been an improvement.” from the report
One incident was not reported promptly
minorAn incident that should have been reported to the CQC was not passed to the manager until after it had been investigated. It happened about 18 months earlier, caused no injury or harm, and the manager agreed to notify the CQC promptly if a similar event occurred.
“On checking the provider's incidents and accidents, we found there had been one incident that should have been reported to us.” from the report
- 01How do you check that any restrictions on a person's freedom are legally authorised and in their best interests?
- 02What changes have you made to make sure incidents are passed to the manager and reported to the CQC promptly?
- 03How are people's care plans and preferences reviewed when their needs change?
- 04How do you make sure there are enough trained staff when someone is off sick or on leave?
- 05What individual activities are currently available, in addition to group activities?
This was an unannounced inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 26 July 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Loretta House
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- June 2020Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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