Inspection on 25/08/09 for UCA House

This inspection was carried out on 25th August 2009.

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

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

Other inspections for this house

UCA House 29/08/08

UCA House 04/10/07

UCA House 16/04/07

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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE UCA House 12 Hall Lane Chapeltown Leeds West Yorkshire LS7 3HE Lead Inspector Dawn Navesey Key Unannounced Inspection 25th August 2009 10:40 DS0000001518.V377374.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address UCA House DS0000001518.V377374.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 19 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (2) of places UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the total of 19 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. 29th August 2008 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 nineteen 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, with communal lounges, dining room and bedrooms, is over three floors. There is a passenger lift to assist people unable to climb stairs. The home has reduced the total number of beds to 19 because one bedroom has been made into a smoking room for people living there. All of the 19 bedrooms have en-suite facilities. There is a small car park and garden at the front of the home. The home should be contacted directly for up to date information about fees. Copies of previous inspection reports are available in the home. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The Care Quality Commission (CQC) 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. More information about the inspection process can be found on our website www.cqc.org.uk This visit was unannounced and was carried out by one inspector who was at the home from 10:40am- 2:00pm and 3:45pm –7:40pm on the 25 August 2009. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who use the service. And also to monitor progress on the requirements and recommendations made at the last inspection. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. An AQAA (Annual Quality Assurance Assessment) was completed by the home manager before the visit to provide additional information. Survey forms were sent out to people using the service, staff and health care professionals. A number of these have been returned and comments have been reflected within this report. During the visit a number of documents and records were looked at and some areas of the home used by the people living at the home were visited. Some time was spent with the people who use the service, talking to them and interacting with them. Time was also spent talking to staff and the deputy manager. Some feedback was given to the deputy manager during the visit. Further feedback was given the following day by telephone to the deputy manager. What the service does well: People said they were happy with their choice of this home. Their comments included: • • It’s good enough here, feel at home. It’s a nice place. DS0000001518.V377374.R01.S.doc Version 5.2 Page 6 UCA House • Very nice here thank you. Staff were familiar with peoples needs and could talk confidently about the support they give. Staff were able to describe peoples personal care needs and what works well for people. A visiting health professional said that they found the standards of care in the home to be good. They said the home follows advice and people always seem well cared for. Staff said the manager was a good manager, open to ideas and suggestions and listens when staff tell her about issues to do with people who live at the home. Their comments included: • • • • Great manager, very fair, good support, couldn’t ask for better. Good manager, makes it a great place to work. Easy to talk to, makes sure the workload is fair. She is fair and decisive. One person living at the home said, “I find the manager just fine”. A relative said, “Manager has open door policy and I feel comfortable to raise concerns”. What has improved since the last inspection? Risk management plans are now more up to date and gave more detail on people’s support needs. The faulty call system has been replaced to ensure people’s privacy In the AQAA, the manager said the environment and safety of the home had improved. Her comments included: • More flats decorated and shower room decorated. • Water heaters replaced. • Training on health and safety. • Records in place for water temperatures. • Records in place for other health and safety risks. Water temperatures are now recorded when checked to show temperatures are safe for people. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 7 What they could do better: Pre-admission assessments should be carried out more thoroughly. This will make sure that peoples needs are properly identified and they are not missed or overlooked. Care plans and risk management plans should continue to be reviewed to make sure people using the service have an up to date, detailed care plan. This will make sure that people receive person centred support that meets their needs. Some consideration should be given to how people can call staff’s attention when in the lounges. This will make sure their needs are more fully met and they receive attention from staff when they need it. An accurate record of the medication received into the home must be kept so that medication can be checked properly and any errors easily identified. Handwritten entries on medication administration records (MAR) sheets should be checked and countersigned by a second person to make sure the information is correct and people receive the right medication. Care plans for people who live at the home should have information about people’s life history, social and leisure interests before they moved into the home. This will make sure that people are then offered activity based on their past and current interests. Staff should be guided and directed to provide a stimulating programme of activities based on peoples needs and choices. This will make sure that peoples social and recreational needs are more fully met.Staffing levels should remain under review to make sure people’s social needs are met fully. Menus should be reviewed to make sure they are meeting the needs of people who live at the home. The television in the lounge must be repaired or renewed. This will make sure people can watch a television that works properly. Staffing levels must be reviewed. This will make sure there are enough staff to meet people’s needs properly and provide adequate supervision for people in the home. Staff should be trained in dementia care to make sure they are aware of current good practice issues and will be able to meet people’s needs fully. Effective systems and record keeping must be in put place to ensure people’s money and valuables are properly safeguarded. This will make sure people are not at risk from financial abuse. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 8 Records in the home must be kept in good order. This will protect the rights and best interests of people who live at the home. The home’s quality assurance surveys should be distributed annually and extended to include people living at the home and health and other professionals. Feedback from the surveys should be analysed, the results published and used to form a development plan for improving the service provided. Staff should receive regular supervision to make sure they are properly aware of their job role and responsibilities and given clear guidance on what is expected of them. Accidents and incidents in the home should be analysed on a monthly basis. This will make sure that any patterns or trends are identified. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 9 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.V377374.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience adequate quality outcomes in this area. The homes admissions procedure does not make sure the home has considered how peoples needs can be fully met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People said they were happy with their choice of this home. Their comments included: UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 11 • • • It’s good enough here, feel at home. It’s a nice place. Very nice here thank you. In the AQAA, the manager said, ‘We assess needs of residents prior to admission’. We looked at pre-admission assessment information for some people recently admitted to the home. We found that the manager had obtained assessments carried out through the care management process which gave some detail on people’s care and support needs. However, we found that the pre-admission assessment carried out by the manager did not give a detailed picture of people’s needs. The assessments did not say how a person was affected by their identified needs, for example, a visual impairment. There was no life history, person centred information to show how people had been considered as individuals. Staff said they had got to know people’s needs through asking them how they wanted to be cared for, information passed on verbally from the manager and using their experience and judgement. This puts people who use the service at risk from having their needs overlooked. Pre-admission assessments should be carried out more thoroughly. This will make sure that peoples needs are properly identified and they are not missed or overlooked. This will also make sure that detailed plans of care are developed from the assessment of the persons needs. The deputy manager told us that as part of the assessment process, people can visit the home with their families to see if the home is right for them. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience adequate quality outcomes in this area. Despite the gaps in care planning documentation, the health and personal care that people receive is, in the main, based on their individual needs. The principles of respect, dignity and privacy are put into practice; however some medication practices put people at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: In the AQAA, the manager said care plans in the home had improved. She said, ‘they are monitored monthly to make sure any changes that are needed are recorded. Individual weight charts added.’ UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 13 We looked at care plan and risk assessment records for some people who use the service. We saw that some risk management plans were now up to date and gave more detail on people’s support needs. We also saw that some care plans had good detail on people’s specific care needs. There were however, still some shortfalls with the care plans and risk assessments. Some plans did not give the detail of how care needs are carried out. Terms such as ‘needs 1 carer’ and needs assistance do not tell staff how much support a person needs and could lead to needs being overlooked. Some risks had been identified for people but were not supported by any management plan. Again this could lead to people’s needs being missed. We therefore still recommend that care plans and risk management plans continue to be reviewed to make sure people using the service have an up to date, detailed care plan. This will make sure that people receive person centred support that meets their needs. The deputy manager told us that senior staff have received more training on care planning and they are intending to introduce new documentation in the near future to improve upon the current system. Despite the gaps in care plan and risk management documentation, staff were familiar with peoples needs and could talk confidently about the support they give. Staff were able to describe peoples personal care needs and what works well for people. As mentioned in the choice of home section of this report staff said they had got to know people’s needs well by asking them how they wanted to be cared for and from using their experience and judgement. A number of staff spoke of how they encourage people to be as independent as possible saying this was good for people’s self esteem and dignity. In the main, people told us they felt well looked after. Their comments included: • • • They look after me good, anything I want they give it to me. Look after us well, always ask us if there is anything we need. Look after us just fine. In surveys returned to us one person answered ‘always’ receive care and support they need. One person said, ‘usually’ and two people said ‘sometimes’. We also asked people if staff listen to them and act upon what they say. Views were mixed, one person said ‘always’, one said, ‘usually’’, one said ‘sometimes’ and another said ‘never’. We also received comments from people’s relatives. These were also mixed. They said: • I am pleased with the overall standard of care. DS0000001518.V377374.R01.S.doc Version 5.2 Page 14 UCA House • Sometimes my father is dressed in clothes that are inappropriate for the weather or temperature. And at times the clothes do not seem to be as clean as they should. Some staff are friendly and chatty and know what they are doing, others are lazy and do the bare minimum. • A visiting health professional said that they found the standards of care in the home to be good. They said the home follows advice and people always seem well cared for. Some people said they felt staff should be more available in the lounge areas as if staff were not in the room it could be difficult to get their attention. During the visit we noticed that some people who needed staff to assist them to move had no way of attracting staff’s attention. They said we just usually shout them. Staff told us that one staff member is always on the floor where the lounges are so that they can hear if people need them. Some consideration should be given to how people can call staff’s attention when in the lounges. It appeared that people who had mobility problems may have to rely on more mobile people to attract staff’s attention. This does not meet people’s needs properly. People look well cared for clean, tidy and well groomed. Attention had been paid to detail. People had clean glasses, people had their hair styled as they wished. Staff were patient and kind when interacting with people. They were discreet and respectful of peoples dignity when attending to any personal care needs. They gave reassurance and explanations for any tasks that they needed to support people with. This seemed to give people confidence in the staff. Help and advice is sought from health care professionals to make sure that people get the special help they need to maintain their health. People are escorted to appointments or health care professionals such as district nurses, attend the home as required. A visiting health professional said they were pleased with the records on health needs kept by the home. They also said the home communicates well with them. Staff said they have been trained to meet the health needs of people who use the service. They said they had received training in diabetes care and management and could talk about how they put this into practice. Some staff have also received training in mental health issues and dementia care. The manager said in the AQAA that she wants to improve the service by making sure more staff complete dementia care training. The home uses a monitored dosage, pre-packed system for medication. All staff have been trained to use the system. The deputy manager said they are now looking into further training for staff that is more in depth and will give UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 15 people a qualification in handling medication. We checked some medication administration record (MAR) sheets. These were found to be in reasonable order. There was one medication that had not been signed for. This was pointed out to the staff member who said it would be investigated. We noticed that some entries on the MAR sheets had been handwritten. It is good practice to make sure these entries are checked and countersigned by a second person to make sure the information is correct and people receive the right medication. We also saw that the amounts of medication received in to the home were not being signed or dated as received which makes it difficult to then check medication and make sure it has been administered correctly. On the day of the visit, we also saw that some medication had been left out in the office and not locked away in the trolley. This leaves people at risk. The deputy manager said this was an oversight and rectified the situation as soon as it was pointed out. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience adequate quality outcomes in this area. Overall, people who use the service have a reasonable range of activity and occupation available to them. Menus in the home may not at times provide people with a varied and healthy diet of their choice. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: In the AQAA, the manager said they had improved the service. She said, ‘residents have had more control over their lives, some of the daily routines have stopped, we have a more person centred approach to care’. She also said she would like to make further improvements to the service and was planning to ‘try to encourage residents to have a more varied daily routine and UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 17 learn about new activities available to them’. She did not say how this was to be done. On the day of the visit, most people said they were satisfied with the activity on offer in the home. They said they enjoyed the church services, watching television, listening to gospel music on the radio and occasionally sitting in the garden. However, we received comments from people in surveys. These are some of the things they said: • Two people said activities were ‘never’ arranged. When people were asked what the home could do better, they said, • • • • • Activities out. Activities in. Days out or people/community organisers coming in to keep us entertained. More activities through the day. Days out. Relatives also commented on activity within the home. They said: • I feel strongly that more activity could be organised, more outings or more people coming in from the community to organise activities such as exercise classes. Also more group activity could be organised such as bingo and dominoes. Some staff also said they felt more could be organised for people. Some staff said it would be better if they had an activities organiser who was skilled in organising activity and motivating people. Others said: • The home could be provided with a mini-bus for the residents to have a day in the park or a country day out. A bit more outdoors would stimulate the residents. Improve the activity of its users by providing a paid activity organiser to meet the needs of its users. • During our visit, people who use the service were watching television or listening to music in the morning. There was no organised activity from staff. In the afternoon a church service was held. This was well attended by people in the home. Staff said that some people go out to day centres and luncheon clubs which give them opportunities to meet up with old friends. They also spoke of a UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 18 recent barbecue which had been enjoyed by people who use the service, their families and staff. A relative said, “Recent barbecue, absolutely brilliant, but a shame only once per year.” Staff also said that they found it difficult at times to motivate people and develop any interest in activities such as games or arts and crafts. Care plans did not show any information about people’s life history, social and leisure interests before they moved into the home. Recording this information would help to make sure care plans were more individual. It could also be used to plan social and leisure activities according to people’s preferences and abilities. Staff said they had time to sit and chat with people or just listen to music with people. They said if they had more staff they would probably be able to get people out more in the local community. One persons care plan said they liked to go out every day to buy a paper. Records showed that this never happened. Staff said they make sure the person gets a paper brought in for them though. People’s views about the food and meals in the home were mixed. They said: • • • • • • • • The food is basic, usually overcooked and not enough thought taken into preparation and/or variety. I don’t think my needs have been taken into account and it is one pot of food for all. Too much snack type food such as egg and beans on toast and not enough Caribbean food. Don’t feel the standard of cooking is always good, depends which chef is on. We get what we want and enjoy it. Depends who’s cooking as to how good it is. Food is lovely but often different to what’s on the menu. Nice food can have whatever we want. The deputy manager told us that menus have been developed based on the likes and dislikes of people who live at the home and include West Indian and Caribbean foods. They are set menus over a two week period. She said they were not usually changed to take consideration of the season or any new likes or dislikes. On looking at the menus, records showed that rarely is the menu adhered to and almost always it is changed from what people think will be on the menu. This means that people do not know what the meal is until they arrive in the dining room. There was some variety of foods but again records showed that baked beans were being given sometimes five out of seven days and ice-cream was given as a pudding when the menu offered a sponge pudding or rice pudding. The deputy manager said it was often people’s choice to have ice- UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 19 cream as a dessert. It is recommended that menus are reviewed to make sure they are meeting the needs of people who live at the home. We observed the lunch time and tea time meal in the home. At lunch time people were offered the choice of pizza or chicken wings, chips and baked beans with yoghurt or fresh fruit for pudding. Some people who didn’t want this were offered a fish cake sandwich as an alternative. At tea time, the meal was grilled haddock or brown lamb stew with rice and vegetables. Pudding was ice-cream or fresh fruit. People said they enjoyed these meals and we thought they looked appetising and well presented. People said they can always have an alternative to what is being cooked if they don’t like it and drinks and snacks are readily available and offered regularly. People are weighed regularly so that their weight is monitored properly. Anyone who is nutritionally at risk is supported to maintain a healthy diet and the manager makes sure professionals such as dieticians or general practitioners are referred to for advice. The atmosphere in the home is relaxed and life seems to go at the pace of people who use the service. People are free to move about the home as they wish and are able to have their things around them. Everyone we spoke to said it felt homely. We looked at records of meetings that are held for people who live at the home. These take place about twice per year. People are asked if they are satisfied with standards of care, the food and activities and staffing issues. A relative said they wished they could be included in these meetings. People who live at the home had asked for a new, larger screen television for the lounge during one of the most recent meetings. The deputy manager said this was being arranged as the television in the lounge goes on and off intermittently. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience adequate quality outcomes in this area. People who use the service are able to express their concerns and are overall protected from abuse. However, badly organised records for people’s personal money could lead to people being at risk from financial abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Most people told us they knew how to complain and said they would talk to the manager or staff if they had any concerns. It was clear from the staffs and deputy manager’s interactions with people that the people who live at the home seemed confident to raise their wishes or concerns. One person said, “Nothing to complain about but would talk to (name of staff)” and another said, “Talk to manager if any complaints”. Two people, however, told us they did not know how to make a complaint. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 21 The complaints procedure is produced in large print and is displayed in the entrance hall of the home. The manager and staff should make sure everyone is aware of the procedure. The home has received two complaints since the last inspection. These have been recorded and investigated. In the AQAA, the manager said the home had improved in that the number of complaints had reduced. Staff have received training in safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. All staff were clear on their responsibility to report abuse or allegations of abuse. They were familiar with the whistle blowing procedure and said they would have no hesitation in using it if they thought they needed to raise concerns outside of the home. The homes safeguarding adults policy contains the contact numbers to enable staff to do this. The manager is familiar with the local authority safeguarding referral system. This means people are properly protected. There have been two safeguarding issues at the home since our last visit. Appropriate referrals have been made by the home and issues have been managed properly. We looked at records for the safekeeping of the money held on behalf of people who use the service. These were badly organised and it was not possible to audit them properly to see if people’s monies were being properly safeguarded. This could lead to people being at risk from financial abuse. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People using the service experience good quality outcomes in this area. Overall, the environment is homely, comfortable and safe for people who live at the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: In the AQAA, the manager said the environment and safety of the home had improved. Her comments included: • More flats decorated and shower room decorated. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 23 • • • • Water heaters replaced. Training on health and safety. Records in place for water temperatures. Records in place for other health and safety risks. People who live at the home said it is always or usually clean and fresh. A relative said, “I am very glad to see the rooms are being redecorated which is long overdue. I hope that the refurb will extend to the communal areas in due course.” A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. On the day of our visit, the decorator was in the home decorating the hall, stairs and landing areas. The deputy manager said that bedrooms were being decorated one per month and then the communal lounges were to be done. We thought the communal lounges were looking a bit tired and worn in their décor and some of the skirting boards looked dirty and dusty. We also thought the toilet and bathroom on the middle floor were in need of new décor to make them more comfortable for people. Again the deputy manager said these were due to be done. People who live at the home were pleased with their bedrooms and had personalised them with their own things such furniture and pictures. As mentioned in the daily life section of this report. Some people said the television in the lounge was broken and went off intermittently. This must be repaired or renewed so that people can watch television without this unwanted interruption. The kitchen was clean and in the main, proper procedures were being followed to promote safe food hygiene practices. However, records showed that fridge and freezer temperatures had not been recorded for the last two weeks and the temperature of meats when cooked had not been recorded for over a week. Staff thoght this may have been an oversight due to the permanent cook being on holiday. However this places people’s health and safety at risk. Staff said they would make sure this was rectified. The home has separate laundry facilities to attend to peoples personal clothing. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who live at the home. Staff have received training in infection control as part of their induction and were able to say what infection control measures are in place. Hand washing and hand drying facilities were available in all areas of the home. Liquid soap or paper towels were available. This ensures good hygiene practice. However, in the laundry area, there were some bars of soap which were dirty looking. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 24 The deputy manager said these would not be used for hand washing as liquid soap was available. She agreed to remove them. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience adequate quality outcomes in this area. Overall, Staff in the home are trained and skilled to support people who use the service and to support the smooth running of the home. However, people do not always have access to enough staff to make sure their care and supervision needs are met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Comments from people who live in the home and their relatives were mixed about staff. Comments included: • • • Staff are lovely, cheerful and polite. They are always very busy and not enough of them. If I want anything they always get it me. DS0000001518.V377374.R01.S.doc Version 5.2 Page 26 UCA House • • • The people are friendly and caring. Lack of consistency from staff. Some staff are friendly and chatty and know what they are doing, others are lazy and do the bare minimum. We looked at rotas in the home and saw that care staffing levels have been reduced since our last visit to the home. The manager no longer has any administration shifts and always works alongside the staff as part of the rostered numbers. There are usually two carers and a shift leader on the morning shift and just two carers on the afternoon shift. The layout of the building means there are rooms on three floors and people may at times be left without supervision with these staffing levels. Staff said they felt that in, the main, they had enough staff to meet people’s needs but all said that if anyone became more dependent and people’s needs changed they would need more staff. They said they felt confident that the manager would arrange extra staffing if needed. During the visit, especially on the afternoon shift, there were long periods of time when people were not supervised in the lounge areas and it was unclear how much interaction people got from staff if they were in their rooms. Staffing levels must again be reviewed to make sure there are enough staff to meet people’s needs properly and provide adequate supervision for people. We looked at the recruitment process for people working at the home. The files had the relevant information to confirm these recruitment processes were properly managed. This included application forms, references and CRB (criminal records bureau) checks. There has been a high turnover of staff this year at the home. In the AQAA, the manager told us that five out of nine staff had left. Staff said that bank staff had been covering the vacancies. The manager runs the induction training on the Skills for Care common induction standards. Staff said they found this useful but had to wait for training courses to back this up, for example, safeguarding adults. We recommend that staff are booked on training courses at the time of their induction so they gain the knowledge to enable them to work through their induction fully. Most staff said they received good training and felt well prepared for their job. One said the home does well by, “Training its staff to work in a professional manner”. However, another said, the home could do better by giving all the necessary training. We looked at training records in the home and saw that most people’s essential training was up to date and most staff have achieved or are working towards an NVQ (National Vocational Qualification) in level 2 or above. Some UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 27 training such as diabetes care had not been recorded on the training plan and only a small number of staff have completed training in dementia care. We therefore still recommend that this is carried out so that staff are up to date on current practice. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience adequate quality outcomes in this area. The management of the home is reasonably well organised. However, some practices do not promote and safeguard the health, safety and well being of people living at the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 29 The home has an experienced and qualified manager who works alongside staff. This however means that she does not have any supernumerary time to carry out her management duties. Staff said she was a good manager, open to ideas and suggestions and listens when staff tell her about issues to do with people who live at the home. Their comments included: • • • • Great manager, very fair, good support, couldn’t ask for better. Good manager, makes it a great place to work. Easy to talk to, makes sure the workload is fair. She is fair and decisive. One person who lives at the home said, “I find the manager just fine”. A relative said, “Manager has open door policy and I feel comfortable to raise concerns”. We received the homes AQAA (Annual Quality Assurance Assessment) when we asked for it. This was reasonably completed and gave a reasonable picture of the home although it was brief in parts, especially when asked to identify what they could do better. In the AQAA, the manager said they were looking to introduce an external quality assurance system. The manager also told us this at the last visit to the home. They do not at the moment have any systems in place for seeking feedback on the service and how it can improve. A relative we spoke to said they would welcome being given a questionnaire so they could comment anonymously. We therefore recommend that the home introduces quality assurance surveys. These should be distributed annually and extended to include people living at the home, their relatives and health and other professionals. Feedback from the surveys should be analysed, the results published and used to form a development plan for improving the service provided. A representative from the United Caribbean Association, visits on a monthly basis to carry out monitoring visits. This involves talking to people who live at the home and to staff. A report of these visits is made showing details of any action to be taken to improve the service. In a recent report they said staff morale was low. All staff we spoke to said this had now been resolved and staff were working well as a team. Records for the safekeeping of the money held on behalf of people who use the service were in place. However, as mentioned in the Complaints and Protection section of this report, these were not in good order. The records were badly organised and it was not possible to audit them properly to see if people’s monies were being properly safeguarded. For example, people had handed over their bank books and debit card for safekeeping but there was no agreement in place to show how this was managed. Bank debit cards and personal identification numbers were being held together for one person. It UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 30 was not clear if the manager was acting as appointee for people or if people managed their own affairs. The personal money records did not show receipts for all expenditure. This leaves people at risk from financial abuse. We sent the home a serious concerns letter the day after our visit asking them to tell us what they are going to put in place to remedy the above and make sure people are properly safeguarded. Staff said they receive supervision from the manager. Some records we looked at showed that staff did not receive regular supervision. Some had not received any for over a year. Staff should receive regular supervision to make sure they are properly aware of their job role and responsibilities and given clear guidance on what is expected of them. As mentioned in the Health and Personal care section of this report, all records such as care plans and risk management plans must be kept to a good standard. More thought should also be given to how people can contribute and be involved in developing their own records. This will make sure plans are more individual and person centred. Arrangements are in place to make sure of safe working practices. The home has a range of health and safety policies and procedures in place. In the AQAA, the manager said that all policies were reviewed and up to date. She also said that all equipment used in the home has been serviced or tested as recommended by the manufacturer or other regulatory body. We also looked at health and safety records in the home. Environmental risk assessments have now been put in place. These were not dated or signed though to say they were current. Water temperatures are now recorded when checked to show temperatures are safe for people. As mentioned in the environment section of this report, the kitchen safety checks such as fridge, freezer and cooked meat temperatures were not properly completed. This puts people’s health and safety at risk. We looked at accident records. These need to be completed to a better standard. We found two accident forms which did not actually state what the accident was. The form that is used to record accidents does not have a space to record any follow up to the accident. And the manager does not complete any analysis of accidents to see if there are any patterns or trends or ways of avoiding future accidents. UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 31 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 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 1 2 2 2 UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement An accurate record of the medication received into the home must be kept so that medication can be checked properly and any errors easily identified. Timescale for action 30/09/09 2. OP19 16 The television in the lounge must 30/10/09 be repaired or renewed. This will make sure people can watch television comfortably without the concern of an intermittent fault with it. Staffing levels must be reviewed. 30/10/09 This will make sure there are enough staff to meet people’s needs properly and provide adequate supervision for people. Effective systems and record keeping must be in put place to ensure people’s money and valuables are properly safeguarded. This will make sure people are not at risk from financial abuse. Records in the home must be DS0000001518.V377374.R01.S.doc 3. OP27 18 4. OP35 OP18 16, 17 09/09/09 5. OP37 16 30/10/09 Page 33 UCA House Version 5.2 kept in good order. This will protect the rights and best interests of people who live at the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations Pre-admission assessments should be carried out more thoroughly. This will make sure that peoples needs are properly identified and they are not missed or overlooked. Care plans and risk management plans should continue to be reviewed to make sure people using the service have an up to date, detailed care plan. This will make sure that people receive person centred support that meets their needs. Some consideration should be given to how people can call staff’s attention when in the lounges. This will make sure their needs are more fully met and they receive attention from staff when they need it. Handwritten entries on medication administration records (MAR) sheets should be checked and countersigned by a second person to make sure the information is correct and people receive the right medication. Care plans for people who live at the home should have information about people’s life history, social and leisure interests before they moved into the home. This will make sure that people are then offered activity based on their past and current interests. Staff should be guided and directed to provide a stimulating programme of activities based on peoples needs and choices. This will make sure that peoples social and recreational needs are more fully met. 2. OP7 3. OP8 4. OP9 5. OP12 6. OP12 UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 34 7. 8. 9. OP12 OP15 OP30 Staffing levels should remain under review to make sure people’s social needs are met fully. Menus should be reviewed to make sure they are meeting the needs of people who live at the home. Staff should be trained in dementia care to make sure they are aware of current good practice issues and will be able to meet people’s needs fully. The home’s quality assurance surveys should be distributed annually and extended to include people living at the home and health and other professionals. Feedback from the surveys should be analysed, the results published and used to form a development plan for improving the service provided. Staff should receive regular supervision to make sure they are properly aware of their job role and responsibilities and given clear guidance on what is expected of them. Accidents and incidents in the home should be analysed on a monthly basis. This will make sure that any patterns or trends are identified. 10. OP33 11. OP36 12. OP38 UCA House DS0000001518.V377374.R01.S.doc Version 5.2 Page 35 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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