Inspection on 13/12/05 for UCA House

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

UCA House 25/08/09

UCA House 29/08/08

UCA House 04/10/07

UCA House 16/04/07

UCA House 25/07/06

UCA House 18/05/05

UCA House 11/01/05

UCA House 20/07/04

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Snydale Care Home

Hawkhills

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Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE UCA House 12 Hall Lane Chapeltown Leeds West Yorkshire LS7 3HE Lead Inspector Paul Newman Unannounced Inspection 13th December 2005 09:30 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 UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service UCA House Address 12 Hall Lane Chapeltown Leeds West Yorkshire LS7 3HE 0113 262 6537 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) United Caribbean Association Mrs Maricia Ann Wrighton Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (2) of places UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the total of 20 beds: One identified service user is under the age of 65 years. One bed designated for respite care may accommodate a service user under the age of 65 years and may fall in the category PD. 18th May 2005 Date of last inspection Brief Description of the Service: UCA House is an established care home that provides residential care for a maximum of twenty service users. The home specialises in providing care for people predominantly (but not exclusively) from an Afro Caribbean origin. The staff group are representative of the ethnic origins that they care for. Specialist categories are restricted to disabled persons admitted for respite care and in addition they may be under 65 years old. Other residents are people who require residential care but do not have specialist care needs. Nursing care is not provided but the home has good links with the Local Healthcare teams. They are able to access any specialised services that they may need. The home is situated in the Chapeltown area of Leeds and is close to shops and other services. Residents are able to attend local day centres thus allowing them to maintain contacts within the local community. There are close links with the local churches and volunteers from these visit the home and offer spiritual support to the residents. Accommodation is provided over three floors that are reached by stairs and a lift. The twenty rooms are all single and have en suite facilities. People are able to bring their own possessions with them. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 18 May 2005. There have been no further inspections until this unannounced visit although an additional visit was made at the manager’s request to discuss the Registered manager’s Award. The people who live in the home prefer the term resident, and this is the term that will be used throughout this report. The purpose of this inspection was to gain an overview of the care, services and facilities provided and also to assess progress in the way the home is dealing with issues that were raised in the last inspection report. During the inspection records were looked at, some parts of the home were seen, such as bedrooms, lounges and bathrooms; care staff were seen carrying out their work; conversations were held with the senior on duty, three other members of staff, a student on placement at the home and six residents. Survey cards were left at the home for residents, relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI). These cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way will be shared with the provider without revealing the identity of those who replied. The inspection started at 9.30 and lasted for four hours, in addition time was spent preparing for the inspection. The manager was not present during the inspection and verbal feedback about what was found was given the week following the inspection. Not all National Minimum Standards were inspected during this visit, but over the two inspections all core standards have been inspected at least once. To gain a full picture of how the home meets standards, this report should be read in conjunction with previous reports. What the service does well: The home is managed with the interests of the residents being the main concern of the manager and staff. The staff are well organised and know the care needs of the residents. The staff are committed and caring people and create a homely atmosphere that is appreciated by residents. Relationships are good and residents feel comfortable and at ease in their surroundings. The food provided reflects the cultural needs of the residents. The Management Committee visits regularly and is aware of what is happening within the home and as a matter of course, talk to residents to make sure they happy with the care provided. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 7 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 UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply in this home. Pre-admission assessments are carried out but do not always form the basis of an initial care plan that demonstrates how the home can meet the residents’ needs when they are admitted. EVIDENCE: The files of three residents were checked. Two were recent admissions and included someone in for respite care. Pre- admission assessments had been completed and were supported by other pre-admission documentation. To fully identify that the home can meet the needs of each resident, an initial care plan must be drafted at the point of admission and this should be discussed and agreed with the resident and/or family. In addition the plan should give clear advice and guidance to staff on how to meet the care needs that are identified so that care is consistently and effectively provided. In the case of the resident on respite care there was no initial care plan drafted and whilst in the discussions with staff they were able to show that they were aware of the resident’s needs, these should have been clearly documented. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. Residents’ care needs are met but this is not fully evidenced in the care plans. EVIDENCE: The care plans must clearly identify care needs and include up to date risk assessments and be evaluated on a monthly basis. It is only through clear and accurate record keeping that the home can fully evidence that individual care needs are being assessed and up dated and the plan gives clear advice and guidance to staff about how to meet needs. There was no plan of care for the resident on respite care although the resident had been in the home for two weeks. In another case the resident had been in the home for six weeks, the pre-admission assessment identified that a chiropodist was needed but there was no evidence that this had been arranged. The same resident was identified as having swallowing problems, this was not clarified and the nutritional assessment stated that the resident ate independently and there had been no weight checks. There had been no review/evaluation of the plan since the resident was admitted. In the third plan, the resident had lived at the home for a year. Although a falls and nutritional risk assessment had been completed on admission these had not UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 10 been reviewed. The plan also showed little evidence of the resident being involved in social and recreational activities. In the discussions with staff it was clear that they were very aware of the care needs and daily lifestyle preferences of individual residents and their relationships were good. So in this respect the indications are that the communication at shift handovers and staff meetings is effective to enable staff to effectively carry out their work. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents are encouraged to make choices regarding their own lifestyle. They are supported to maintain contact with family and friends and visitors are welcomed at the home. A good, varied and nutritious diet taking into account individual choices is provided at the home. EVIDENCE: There were two residents out at day centres, this being a consistent feature of home life for a number of residents so that they can maintain links with the local community and their friends. Some also regularly attend a ‘stroke club’. Some activities are organised in house including prayer meetings and there are occasional trips out. There had been a recent trip to the cinema to see the new version of King Kong. Residents said that they receive regular visits staff always make them welcome. Getting decided by the individual resident and they spending time in their rooms and going into like it. from family and friends and that up and going to bed times are are able to enjoy the choice of communal areas when they feel Residents said that the food was generally good. They have a snack lunch and their main meal at teatime. Menus provide for choice including English and Caribbean food to try and meet the cultural diet preferences of the residents. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None inspected. These standards were not inspected. EVIDENCE: UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The home offers a safe, well-maintained environment for the residents. People are able to personalise their bedrooms. EVIDENCE: There is an ongoing programme of redecoration and refurbishment within the home in addition to regular maintenance taking place. Since the last inspection both lounges and the hall way have been redecorated, as have the communal bathrooms. Some light fittings have been replaced. Sufficient toilets are available for people to use near to the communal rooms that can accommodate wheelchairs or mobility aids. Soap and towels were seen in all of the toilet areas. There are different types of assisted bathing facilities so residents can use the one of their choice. The individual bedrooms are a good size and all have en suite facilities. Residents are encouraged to bring their own possessions with them including furniture if it meets with safety requirements. Some people had brought UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 14 furniture and everyone had photographs and other personal mementos around them. All the rooms can be locked and the residents can hold the key. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, and 30. The numbers and skill mix of staff were sufficient to meet the needs of the service users. Staff are trained and competent to do their jobs. EVIDENCE: The staff numbers were appropriate at the time of the inspection and residents and staff confirmed that this is the normal way of working. Staff rosters also confirmed the numbers on duty at any given time. The home continues to benefit from a stable staff group that offers the residents consistency in the care give and familiar faces on a day-to-day basis. Further progress has been made in the numbers of staff holding NVQ qualifications and the targets that have been set for the numbers of staff who should hold a qualification should be achieved by the summer of 2006. In speaking with the staff on duty they confirmed that safe working practice training was up to date but further training will need to be arranged during 2006 to make sure they are kept informed of current practice. It is recommended that training on abuse and the protection of vulnerable adults take place to open up discussion about day-to-day practices. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37 and 38. The interests of the residents are very important to the manager and staff who do their best to promote the safety and welfare of the people who live in the home. EVIDENCE: The manager continues to work towards the Registered Manager’s Award and following a short period of difficulty is approaching the award with a renewed confidence. The discussions with residents continue to confirm that they have confidence in the staff, think that they are caring and they have good relationships. They feel comfortable in raising problems and say that staff listen and put things right. The management committee make regular visits to the home and as a matter of routine talk with residents to check that they are satisfied with the care provided. Key workers also continue to make quality checks of residents’ rooms. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 17 Staff spoken with said that they had requested that staff meetings are more regular than the current quarterly meetings and morale did not appear to be as good as on previous inspection visits. Some issues raised by staff were fed back to the manager for her to consider. In discussion with the cook about menus it was noticed that the menu was not always followed, but there was no written record of this. The home must keep a record/diary of the food actually provided to residents. Fire safety documentation was checked and drills and system checks were being held regularly although it was noted that fire extinguisher servicing was due during December/January. It was disappointing to find hazardous substances left unattended in one of the bathrooms in what is normally a well maintained and hazard free environment. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 18 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X 2 2 UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 19 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 15 Timescale for action Pre-admission assessments must 01/03/06 form the basis of a care plan that is in place when residents are admitted and has been agreed with the resident and or their relative, so that the home can demonstrate it can meet the needs of the individual. Care plans must fully identify the 01/04/06 care needs of residents, include up to date risk assessments and be evaluated each month. A minimum of 50 of all care 01/07/06 staff must have achieved a minimum of NVQ level 2 or equivalent within the timescales. The manager must have 01/07/06 completed the registered managers award within the expected timescales. An accurate record of the food 01/03/06 actually provided must be kept. The record must be in sufficient detail for inspecting officers to determine that diet is satisfactory, the nutritional benefits and any special diets. Hazardous substances must not 13/12/05 be left unattended. DS0000001518.V270370.R01.S.doc Version 5.0 Page 20 Requirement 2 OP7 15 3 OP28 18 4 OP31 9 5 OP37 17 6 OP38 13 UCA House 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 Refer to Standard OP30 OP32 Good Practice Recommendations It is recommended that all staff are involved in group training sessions about abuse and adult protection to open up discussions about day-to-day working practices. It is recommended that staff meetings are held more regularly (monthly) as requested by some members of staff. UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI UCA House DS0000001518.V270370.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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