Inspection on 16/04/07 for UCA House

This inspection was carried out on 16th April 2007.

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 25/07/06

UCA House 13/12/05

UCA House 18/05/05

UCA House 11/01/05

UCA House 20/07/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

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 Ann Stoner Unannounced Inspection 16th April 2007 10:30 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.V335589.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. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 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.V335589.R01.S.doc Version 5.2 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. 25th July 2006 Date of last inspection Brief Description of the Service: UCA House is an established care home that provides residential care, without nursing, for a maximum of twenty people over the age of 65. It is situated in the Chapletown area of Leeds, close to shops, places of worship and public transport. The home specialises in providing care for people predominantly (but not exclusively) from an African Caribbean origin, with a staff group that is representative of the ethnic origins of the people who live at the home. Accommodation is over three floors with a passenger lift to assist people unable to climb stairs. There are 20 single bedrooms all of which have en-suite facilities. There is a small car park at the front of the home. Fees that applied at the time of this inspection were stated in the preinspection questionnaire as ranging from £353.00 - £358.65. More up to date information may be obtained from the home. Copies of previous inspection reports are available in the home. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. During the site visit, homes are judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the site visit. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. Further information about how we inspect can be found on the website at www.csci.org.uk This site visit took place on the 16th April 2007 between 10.30am and 6.30pm. The purpose of the visit was to make sure the home was operating and being managed for the benefit and well being of the people who there and in accordance with requirements. Before the visit accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. A number of documents were looked at during the visit and some areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager, staff, a GP, social worker and a visitor. The manager completed a pre-inspection questionnaire (PIQ) before the visit to provide additional information about the home. Survey forms were sent out before the visit to the people who use the service, such as relatives, carers, general practitioners and other healthcare professionals. Several were returned and information provided in this way will be reflected in the report. I would like to thank everyone who contributed to this report, and for the hospitality on the day. What the service does well: The home is well positioned close to the heart of the African Caribbean community giving people the opportunity to remain in close contact with old friends and neighbours. The ethnic diversity of the staff group represents that of the people who live at the home, this gives staff a better understanding of people’s cultural needs. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 6 Bedrooms are spacious and people are able to personalise them with their own belongings. There is a warm and friendly atmosphere in the home, where visitors are welcomed. There are facilities for visitors to stay overnight. What has improved since the last inspection? What they could do better: The home must provide people with sufficient information before admission so that they have accurate and up to date details about the home. The home should make sure that a pre-admission assessment is carried out before any decision about admission is made. This will make sure that the home can meet the person’s needs. To prevent unauthorised access to medication staff must not leave the medication trolley unattended and unlocked. Staff must follow correct procedures when giving out medication by completing the Medication Administration Record at the time they give each person their medication. Medication must only be given to the person that it has been prescribed for. This should make sure medication practices are safe. The emergency call system must be updated or replaced. This will make sure that private conversations are not overheard and respect people’s privacy. Some minor repairs must be carried out to make sure that the premises are safe and suitable for people living at the home. Proper recruitment checks must be carried out to make sure that job applicants are suitable to work with vulnerable people. Discussions with staff show that the health, personal and social care needs of people living at the home are met. However, care records do not provide clear evidence of this, creating a potential risk of care needs being overlooked. The manager must make sure that detailed care plans are in place for all the people living at the home. This should ensure staff have clear instructions on how to deliver care and will provide evidence that care needs are being met. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 7 A quality assurance system must be developed. This will provide the home with feedback so that improvements can be made for people living at the home. When bed safety rails are in use a risk assessment and safety checks must be carried out. This will ensure the safety of people using them. Doors must not be wedged open. This will ensure the safety of people in the event of a fire. There are two staff and one person in charge of the shift throughout the day to provide care for up to 20 people. This may not be enough staff to make sure that the people living at the home are properly supervised and their care needs met. The provider has been asked to review this situation to make sure that the well being of the people at the home is not being compromised. The manager is supported by a part-time deputy and a senior carer, none of whom have any time dedicated to management. This affects the way that the home is managed and is reflected in the number of requirements and recommendations made as a result of this visit. The registered providers should review this situation. A full list of requirements and recommendations made as a result of this visit can be found at the end of this report. 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. UCA House DS0000001518.V335589.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 UCA House DS0000001518.V335589.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, & 5. Standard 6 does not apply to this home. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Accurate and up to date information about the home is not available to people before admission. This could leave people feeling excluded from the admission process. Poor pre-admission planning creates a risk that specialist care needs will not be met. EVIDENCE: Information is available to people and their families in the form of a statement of propose and service user guide, but these documents do not include all of the required information such as size of rooms, the range of needs to be met, the number, qualification and experience of staff working at the home. The manager was unaware that information on what should be included in the statement of purpose can be found in the Care Home’s Regulations 2001 and on the CSCI website. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 10 Information in returned survey cards from people living at the home show that they have the opportunity to visit the home before the point of admission, but some comments indicate that they are not always fully involved in the decision making process. For example one person said, “My son decided to send me to UCA” and another said, “I was just informed I had to leave hospital and come to UCA.” The care records of three people were looked at. In all three there was an Easy Care Assessment completed by a social worker, but there was no evidence to show that the home had carried out its own pre-admission assessment to identify whether or not it could meet the person’s needs. One person had been admitted under Section 17 of the Mental Health Act but the home had failed to discuss this with CSCI staff and therefore had arranged an admission outside of its registration category. All five returned survey cards from people living at the home said that they had received a contract. UCA House DS0000001518.V335589.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There is a risk that people will not receive the care they require because of the way that staff receive information. Safe systems of medication administration are not always followed. This could pose a potential risk to people. EVIDENCE: The care plans of three people were looked at in detail and in all cases the level of information recorded was poor. People’s precise needs were not accurately identified and there was little or no detail for staff on how to deliver the care required. One person had no details recorded about personal care, dressing and grooming, continence, bed safety rails, mental health or night care. Another person’s records showed that she was a diabetic, had lost weight but was still eating a good diet, had been investigated at hospital and was at risk of falling due to her prosthesis. The only care plan in place was one for personal care, which said, “Needs assistance and prompting with personal hygiene and appearance.” There was no nutritional or falls risk UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 12 assessment in place. The third person was admitted under Section 17 of the Mental Health Act, and is now subject to a Guardianship order under Section 7 of the Mental Health Act. There were no care plans in place for mental health, diabetes, personal care, bathing, grooming, night care and recreation and leisure. From discussions with staff it was clear that they knew about the individual needs of people, but this was from verbal information passed from one staff member to another, rather than recorded information. This form of communication places residents at risk of having their needs overlooked. Some information about residents is recorded in a general communication book rather than in individual care plans. This contravenes the Data Protection Act. Care records showed people having chiropody, GP and district nurse visits. During the visit one visiting GP said that she felt the home manages diabetes very well, and there was good communication between the home, GP and diabetic link nurse. The home now uses a Nomad system for medication, which is prepared by a pharmacist. A member of staff was observed administering medication. The medication trolley was left unattended, giving the opportunity for unauthorised access and MAR (Medication Administration Records) were not completed at the time of administration. The home does have a homely remedy policy but this needs amending and updating. During a discussion with the manager it became clear that medication such as Paracetamol, is sometimes used for people other than the person it was prescribed for. Staff described how they protect the privacy and dignity of people, but the home’s emergency call system allows conversations in people’s bedrooms to be overheard. This is an intrusion of their privacy. UCA House DS0000001518.V335589.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The cultural and religious needs of people are respected, but the amount of activities available to people is restricted by staffing levels. This leaves some people with little to keep them occupied. EVIDENCE: Staff spoke about the choices available to people, such as times for getting up in the morning and going to bed at night, choice of menu, and whether or not to join in any activities. This was confirmed by observation during the day and when speaking with people living at the home. Staff spoke about the different religious needs of people and of how these needs are met by the various visiting ministers, priests and others. Staff are compiling a life history for each person, which gives them an insight into the person’s life before they came to live at the home. Two staff said that this had provided them with previously unknown information that one person liked horse racing. As a result of this they were able to have a discussion with him about betting odds on the Grand National. This is good practice. Staff said that they try to organise activities whenever they can, but they find it UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 14 hard to motivate people with dementia. Activities recorded in people’s records were mainly TV, attendance at a day centre or listening to music. Returned survey cards from people living at the home showed conflicting views, some thought that there were usually enough activities whilst others thought not. A visitor said that staff are always busy and have little time to spend with people. The home would benefit from an activities co-ordinator who is supernumerary to the care staff rota. The home encourages visitors and has facilities for overnight accommodation. There is a choice at meal times with Caribbean regularly offered. UCA House DS0000001518.V335589.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The policies, procedures and staff knowledge mean that people living at the home can feel safe. EVIDENCE: The home has received 8 complaints during the last 12 months, all were recorded, but not all were followed by details of the investigation and subsequent action. The manager agreed to rectify this. Four out of five returned survey cards from people living at the home said that staff listened and acted on what they had to say and they knew how to make a complaint. The home has an adult protection policy and staff on duty during this visit knew about the different types of abuse and how to report any suspicions or allegations of abuse. The manager is undertaking a ‘train the trainers’ course on adult protection so that she can cascade this to other staff in the home. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 16 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): 19 & 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall the environment meets the needs of the people living at the home, but there is a risk that their privacy may not always be preserved. EVIDENCE: All areas of the home were clean, tidy and free from any offensive odours. Communal lounge areas are comfortable and well furnished. Those bedrooms seen were spacious, personalised according to individual taste and had ensuite facilities. Those people who are able are offered a key to their room. As identified earlier in this report peoples’ rooms are fitted with an emergency call system, but this is now outdated because in some circumstances it allows the opportunity for conversations to be overheard. This is an intrusion on people’s privacy and must be addressed. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 17 The home has two bathrooms and one shower room. The manager said that people did not like the shower and therefore this room was not used. At the time of this visit it was being used to store wheelchairs, a hoist, a floor cleaner and cleaning liquids. The shower room ceiling is in need of repair following a leak; this had not been reported to the manager. Damage to a kitchen door, identified at the last visit, has still to be addressed. Staff have a good understanding about how to stop the spread of infection in the home and several are undertaking a distance learning pack on infection control. Liquid soap and disposable towels are provided in all areas where clinical waste is handled. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29 & 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Recruitment does not always guarantee that staff are suitable to work with vulnerable people. The numbers of staff on duty are not appropriate for the number and needs of people living at the home. EVIDENCE: The home is registered for 20 people but at the time of this visit the home had five vacancies. The rota shows that throughout the day there are 2 care workers and 1 senior staff on duty. During the day care staff undertake laundry duties and at weekends they also carry out cleaning duties. This gives little dedicated time for staff to spend with people, although staff did say that if peoples’ needs change the manager increases staffing levels by using ‘bank’ workers. The manager said that she felt peoples’ dependency levels were low and that the current staffing levels were appropriate. The pre-inspection questionnaire however identified that there are 2 people with high needs requiring 2 members of staff to assist them, 3 people with medium needs, and a number of people with dementia, mental health, continence, and personal care needs. In view of this, staffing levels in the home should be reviewed. During the visit one visitor said that she felt there was not enough staff, they were always rushing and didn’t have time to spend with people. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 19 Staffing in the home is diverse and reflects the culture of the people who live at the home. The home’s rota shows staff working ‘E’, ‘L’ and ‘on’, rather than the exact hours each person works. The pre-inspection questionnaire completed by the manager before this visit shows that 72 of staff have achieved a National Vocational Qualification and all hold a first aid certificate. The manager said that training needs are identified through individual supervision sessions with staff and as a result of appraisals. Training during the last 12 months has included infection control, catheter care, fire training and medication training. All new staff complete an induction workbook, but this has not been updated to meet the Skills for Care induction standards. The manager agreed to look into this. The recruitment records of two members of staff were sampled. In both cases the application form did not require the applicant to list a full employment history. In one file there was only 1 written reference and 1 verbal reference, and in both cases the photograph of the staff member was a photocopy of the person’s passport photograph, which in some cases can be difficult to distinguish. Because one person had a successful CRB/POVA (Criminal Record Bureau/Protection of Vulnerable Adults) check within the last 12 months, the manager had not requested another. The manager was unaware that CRB/POVA checks are not transferable. The home keeps the CRB/POVA disclosure number and the issue date rather than the full disclosure form. This should be retained until the next inspection. The manager agreed to rectify this. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 37 & 38. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The rota does not allow the manager to carry out the requirements of her role. The health, safety and welfare of residents are not properly managed and some practices place residents at risk. EVIDENCE: The manager has completed a Health & Social Care course and has almost completed an NVQ (National Vocational Qualification) Level 4 in Management. Staff said that she always challenges poor practice and is approachable and fair. A part-time deputy and two senior care workers support the manager, but none have any dedicated management time. This allows little or no management work to be done and is reflected in the requirements made as a result of this visit and in the home’s poor record keeping. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 21 Meetings are held for people who live at the home but the minutes show that these only take place twice a year, and there is little evidence to show that people are involved in all aspects of the home. There is no formal quality assurance system in place but the manager said that the views of relatives and people living at the home are sought informally. A representative of the management committee visit the home regularly, but these visits are announced and regulation 26 visit reports are not completed despite this being discussed at the last CSCI visit. A member of the management committee is appointee for one person. The manager said that the appointee holds the person’s savings book. The manager does not have access to this and is unaware of when withdrawals are made and of the current balance on the account. Details of all financial transactions must be made available in the home for inspection. Financial transactions made on behalf of other people living at the home did not have two signatures and signatures are not always obtained from people handing over money for safekeeping on behalf of someone living at the home. The pre-inspection questionnaire completed by the manager shows that servicing takes place as required. Fire alarm tests are carried out weekly and the manager is now trained to cascade fire training to other staff in the home. The manager analyses accident records as part of a monthly report for the management committee. A number of accident records were seen. Where an accident is not witnessed by staff there is no record kept of when the person was last seen and by whom. A number of doors were propped open by wooden door wedges, which creates a hazard in the event of a fire. A bed safety rail risk assessment was not completed for one person with bed safety rails in place. Safety checks on bed rails do not take place, and staff were unaware of what they should be looking for when carrying out checks. This creates a potential risk for those people using bed safety rails. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 22 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 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X 1 2 UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4 (1) (c) Requirement All people using the service must have access to an accurate and up to date Statement of Purpose that includes all of the information specified in Schedule 1 of the Care Homes Regulations 2001 This will ensure they have sufficient information about the home before the point of admission All people using the service must have an up to date, detailed care plan. This will ensure that they receive person centred support that meets their needs. Timescale for action 31/08/07 2 OP7 15 (1) 31/08/07 3 OP9 13 (2) The previous timescale of 31.10.06 is unmet. Medication must be held securely 17/04/07 at all times. Staff must complete Medication Administration Records at the time that they give each person their medication. This will prevent mistakes and make sure that correct procedures are followed. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 24 4 OP10 12 (4) (a) 5 OP19 23 (2) (b) 6 OP29 19 (1) (b) Medication must only be given to the person that it has been prescribed for. The emergency call system must 31/12/07 be updated or replaced. This will make sure that people’s privacy is respected. The shower room ceiling and 30/06/07 damage to a kitchen door must be repaired to make sure that the premises is safe and suitable for people to live in. Staff must not be employed until 17/04/07 the home has received 2 written references and a Pova first or CRB/POVA disclosure check has been returned. This will make sure that job applicants are suitable to work with vulnerable people. A system of monitoring and evaluating the quality of care in the home must be developed. The registered providers must carry out unannounced visits in line with regulation 26 of the Care Homes Association. A report of the visit must be completed with copies given to the manager, CSCI and members of the United Caribbean Association management committee. This will provide the home with feedback so that improvements can be made for people living in the home. A bed rail risk assessment must be carried out whenever bed safety rails are being considered. If bed safety rails are in use safety checks must be carried out. 7 OP33 24 (1) 26 31/08/07 8 OP38 13 (4) (c) 16/05/07 UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 25 9 OP38 13 (4) (a) This will ensure the safety of people using bed safety rails. Doors must not be wedged open. 17/04/07 This will ensure the safety of people in the event of a fire. 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 Refer to Standard OP3 OP7 OP7 Good Practice Recommendations The home should carry out a pre-admission assessment to make sure that it can meet the person’s individual needs. Nutritional and falls risk assessments should be carried out when a person is admitted, and repeated as necessary, so that people at risk are properly identified. All information recorded about people should be in their care plan and not in a general communication book. This will ensure that the requirements of the Data Protection Act are complied with. The home should consider recruiting more staff so that people have access to recreation and leisure suited to their past and present interests and abilities. The numbers of care staff on duty throughout the day should be reviewed taking into account the dependency of the people living at the home and the layout of the home. This is to make sure that the safety and well being of people living at the home is not compromised. Application forms should be updated to show the job applicant’s full employment history. An original photograph of staff members should be held on their file rather than a photocopy of their passport photograph. CRB/POVA disclosure checks should be retained on staff files until after each inspection visit. This should make the home’s recruitment systems more robust. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 26 4 5 OP12 OP27 6 OP29 7 OP31 The manager’s duty rota should be reviewed so that she has dedicated management time. This should improve the management of the home. In all cases where the manager or registered provider is appointee for someone living at the home, records of all financial transactions should be available at all times. Two signatures should verify all transactions made on behalf of people living at the home. Where money is handed over on behalf of a person living at the home a signature should be obtained from the person handing over the money and the person receiving the money. This will reduce the risk of financial abuse. 8 OP35 9 OP38 If an accident is not witnessed a record should be made of when the person was last seen and by whom. UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 UCA House DS0000001518.V335589.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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