CARE HOMES FOR OLDER PEOPLE
UCA House 12 Hall Lane Chapeltown Leeds LS7 3HE Lead Inspector
Kathleen Firth Unannounced 10.30 am 18 May 2005 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 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 J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Uca House Address 12 Hall Lane Chapeltown Leeds LS7 3HE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 262 6537 United Caribbean Association Mrs M Wrighton Care home 20 Category(ies) of Old age (20) Physical disability (2) registration, with number of places UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 11.01.05 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 provideing 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 J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 18th May 2005 over four hours by one inspector. The inspector toured the building, spoke with residents, staff, deputy manager and a member of the Home’s Management Committee, examined residents’ records including care plans, menus, staff rosters and the Service User Guide. The Deputy Manager, staff, residents and the management committee member were all helpful throughout the inspection and were happy to join in the process. Eleven residents and three members of staff were spoken to along with the deputy manager. What the service does well:
Each resident is assessed to ascertain their needs prior to their admission in addition to spending time at the home. All residents has a comprehensive care plan in place with all of their needs clearly identified. Alongside the needs the tasks required to meet these are recorded. Links with the local community are maintained through various methods and these are important to everyone at UCA. All relevant records examined are well maintained and were up to date. Residents are encouraged to be independent and those spoken to said that they feel able to speak to the manager and staff if they have any particular worries or concerns. They confirmed that they are able to go to bed/ get up when they choose and are free to go out with relatives or alone if this has been agreed in their care plan. All residents spoken to confirmed that they are well looked after and that staff are always polite and helpful. They also said that the meals are very good and that there is usually an alternative for them to choose. Staff feel well supported by management and most said that it is a good staff team at the home. Most staff have worked at the home for a long time thus ensuring continuity of care for the residents. There is a commitment to training at the home and there is a Training Programme in place. People are working on NVQ. and are at varying stages.
UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 6 The Management Committee member confirmed that they are always prepared for staff to attend relevant courses that will help them improve their care of residents. The Management Committee visits regularly and is aware of what is happening within the home. What has improved since the last inspection? What they could do better:
Resident’s files need to be kept in a more consistent way in order to make them more meaningful. Staff files need to be kept in a more consistent way and contain the same information. If there are no changes to care plans at the time of the review, this needs to be recorded. UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 7 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 J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 5 People are able to make an informed decision about the home from the written information they receive and from what they see when they visit the home. EVIDENCE: A copy of the home’s brochure that was seen to contain sufficient information to enable people to make an informed choice about the home is given to all prospective residents. Everyone is assessed prior to been admitted to the home to ensure that staff will able to meet their needs. The preadmission assessments were present in the individual files seen at the inspection. All prospective residents are invited to spend a day at the home. Residents spoken to said that this had been useful to them and had helped make the decision about moving in. Where people are unable to visit their families are invited to come and look around. It is normal practice for prospective residents to visit for the day alone and families come at a different time. This is because the day visit is seen as part of the assessment and it is felt that people react better when relatives are not present. One lady said she had spent a day at the home and then visited again with her son.
UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8, 9, 10 Staff treat residents with dignity, maintain their privacy at all times and show an awareness of the residents’ needs. EVIDENCE: Comprehensive care plans are in place for all residents and were seen to contain the needs of the residents and what tasks were required to be done in order for staff to meet these needs. The plans were clear, concise, easily understood and contained healthcare and social needs. There was evidence that the plans are reviewed and updated on a regular basis. Staff had failed to record where there were no changes to the plans following a review. No residents look after their own medication other than laxatives and inhalers and the home has a comprehensive medication policy in place to manage this. The home uses the nomad system for medication and their ordering, storage, administration and disposal of medication was seen to meet the standard. All records examined were seen to be accurate and up to date. All residents spoken to said that they felt well looked after and that staff were all helpful and kind. One lady said that she felt so much safer in the home than she had before coming and that her health had improved. Staff were
UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 11 seen to knock on bedroom doors before entering and the residents spoken to said that the staff treated them with respect. Residents are able to lock their door if this is their choice. Visits from GPs, District nurses and other health professionals were recorded and evidence was seen that the residents’ healthcare needs are met. Where any visiting professionals’ visit had resulted in any action required, this was clearly recorded. The deputy manager said that the home receives excellent support from the local healthcare team and that there are no problems with requesting visits. UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14, 15 Residents are encouraged to make choices about their own lifestyle and to maintain contact with family/friends/community where possible. A good, varied nutritious diet taking into account individual choices is provided at the home. Some activities are offered at the home. EVIDENCE: People spoken to confirmed that they feel able to voice their opinions and are listened to when they do so. Some residents go out to local Day care centres thus allowing them to maintain contacts with the local community. Visitors are welcome to come at any reasonable time and, where it has been agreed in the care plans residents are able to go out with their families. Residents spoken to confirmed that they could go to bed/get up at the times they choose. They can sit in their rooms if this is their choice and one lady said that she does this but that staff are always available to do things for her. There are regular prayer meetings held at the home and some residents go out to their own church. Religious ministers are welcomed to visit the home. The staff organise activities and outings for the residents that meet with preferences and take into account peoples’ abilities. One member of staff was seen to play dominoes with the residents and another was taking time to talk to another. One lounge was set up with a television and another with music that some residents were singing along with.
UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 13 The residents have their main meal of the day in the evening. The snack lunch served during the inspection was sufficient and residents were seen to enjoy this. The people spoken to said that they liked the idea of having a cooked meal at teatime, as this is what they had been used to at home. The menus confirmed that the home serves a mixture of English and Caribbean food to try and meet the cultural diet preferences of the residents. Most of the residents spoken to were happy with the food but one man said that the meals were okay sometimes but not at others. UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16, 17, 18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents have their rights protected. They are protected from abuse. EVIDENCE: The appropriate policies and procedures were seen to be in place and staff confirmed that they had had Adult Protection training. Residents are given a copy of the Complaints procedure and a copy is displayed on the home’s notice board. Evidence was seen that a recent complaint was been dealt with in the correct way. Most of the residents spoken to were able to confirm that they feel able to speak to the management and staff if they have any concerns and these are dealt with quickly and appropriately. Residents confirmed that they were able to vote in the recent election. Some had used the postal system whilst others had gone to the polling station. The deputy manager said that no candidates had visited that home but that they had all sent in literature that staff gave out. UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 21, 23, 24, 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. Evidence was seen of electrical installations and appliance checks. There is a call system throughout the home and staff ensure that the pull-strings are within reach of people choosing to sit in their rooms. 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 very big and all have en suite facilities. Residents are encouraged to bring their own possessions with them including furniture if
UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 16 it meets with safety requirements. Some people had brought furniture and everyone had photographs and other personal mementos around them. One lady had her own fridge and telephone. One resident said that she liked her room and was getting used to living at the home. All the rooms can be locked and the residents can hold the key. The general appearance of the home is clean, tidy and hygienic. The stairs and corridors were all clear of any hazards and handrails are in place. The laundry is away from the residents’ rooms and met with the standard. One lady said that she was very happy with the laundry service in the home. UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Residents are supported and protected by the robust recruitment procedures. Staffing numbers and skill mix ensure that residents’ needs can be met. EVIDENCE: The staff numbers were appropriate at the time of the inspection, 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 has a static staff team that helps to promote continuity. Staff files confirmed that written references plus CRB checks are obtained before staff can start working at the home. Evidence was seen that all new staff have induction training. Regular staff meetings are held. Staff spoken to said that they are able to attend training courses and the deputy confirmed that they receive payment for these. The Management Committee of the home makes decisions regarding the training budget but there are no problems in management or staff been able to access appropriate training. The home has a training programme in place. 50 of staff should have completed the NVQ level 2 awards by the end of this year. UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36, 38 The interests of the residents are seen as very important to the manager and staff and are safeguarded at all times and the home is well managed. EVIDENCE: Three residents manage their own finances and families deal with the rest. Any money that the home is responsible for is kept in the safe and appropriate records kept of any transactions undertaken. All records seen at the inspection were seen to be correct. Regular staff supervision sessions with written records are in place and evidence of this was made available at the time of the inspection. All staff spoken to said that the manager and her team were all supportive. The manager is still working on the registered manager’s award and should complete this within the target date. There is an awareness of Health and Safety in the home and nothing was seen during the inspection that was deemed dangerous to either residents or staff.
UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 19 The home has a Quality Assurance system in place. The Management committee meets monthly and monitors the performance and achievement of the home. Members of the management Committee make visits to the home when they ensure that everything is running smoothly and listen to the views of the residents. One member of the Management Committee was present at the time of the inspection. UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 x 3 3 x 3 UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? 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 OP 28 Regulation 18 Requirement A minimum of 50 of all care staff must have achieved a minimum of NVQ level 2 or equivalent within the timescales. The manager must have completed the registered managers award within the expected timescales. Timescale for action 31.12.05 2. OP 31 9 31.12.05 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 37 29 Good Practice Recommendations Resident files need to be more consistent in their content and the order they are kept in. Staff files need to be more consistent in their content and the order they are kept in. UCA House J52 S1518 UCA V226979 180505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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