Inspection on 25/07/06 for UCA House

This inspection was carried out on 25th July 2006.

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

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

Other inspections for this house

UCA House 25/08/09

UCA House 29/08/08

UCA House 04/10/07

UCA House 16/04/07

UCA House 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 Sue Dunn Key Unannounced Inspection 25th July 2006 10:00 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.V304778.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.V304778.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.V304778.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. 13th December 2005 Date of last inspection Brief Description of the Service: UCA House is an established care home that provides residential care for a maximum of twenty service users. The home specialises in providing care for people predominantly (but not exclusively) from an Afro Caribbean origin. The staff group are representative of the ethnic origins that they care for. Specialist categories are restricted to disabled persons admitted for respite care and in addition they may be under 65 years old. Other residents are people who require residential care but do not have specialist care needs. Nursing care is not provided but the home has good links with the Local Healthcare teams. They are able to access any specialised services that they may need. The home is situated in the Chapeltown area of Leeds and is close to shops and other services. Residents are able to attend local day centres thus allowing them to maintain contacts within the local community. There are close links with the local churches and volunteers from these visit the home and offer spiritual support to the residents. Accommodation is provided over three floors that are reached by stairs and a lift. The twenty rooms are all single and have en suite facilities. People are able to bring their own possessions with them. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection visit was to ensure the home was operating and being managed for the benefit and well being of the residents. One inspector undertook the inspection, which was unannounced. The inspection started at 10.30 am and finished at 4.45 pm A pre inspection questionnaire sent to the manager had been completed at the time of the inspection. Comment cards with pre paid envelopes were left in the home inviting people to express their views about the service. Responses had been received from a resident and a health professional at the time of writing. The comments supported evidence gathered at the time of the visit. The report is based on information received from the home since the last inspection; observation and conversation with residents and staff, examination of 4 care files (which included case tracking two) and an inspection of the premises. This included an inspection of some bedrooms and all communal areas. The fee is £353 per week. This does not include hairdressing, chiropody, personal toiletries, personal clothing, magazines and newspapers or the cost of activities, which take place outside the home. The manager expressed concerns about the people who were not receiving their personal allowances through their families on a regular basis. It is understood that the person in control of the organisation is to write to the people responsible as this is a form of financial abuse. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Overall the monitoring and evaluation of care recording was good and showed residents, relatives and staff had been involved in the process. Any changes to the set menu are now recorded in a book for that purpose. All the daytime care staff have had Adult Protection training. The home enrols staff on the ‘fast track’ NVQ programme which has resulted in over 50 of care staff who have achieved the NVQ award. Staff meetings are now being held monthly and give everyone the opportunity to express their views. Staff spoken with felt everyone worked well as a team. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. UCA House DS0000001518.V304778.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.V304778.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 Quality in this outcome area is adequate. This judgement is based on inspection of two documents describing the terms and conditions of occupancy, inspection of the pre admission assessments in four care files, examination of care files and discussion with staff. The licence to occupy is clear about the terms and conditions of occupancy. The manager is right to insist on satisfactory assessment information from referral agencies. However, the information she gathers for the home’s assessments should be sufficient on which to base an action plan so that people can be assured their needs will be met when they enter the home. EVIDENCE: The home does not provide intermediate care. A ‘Licence to Occupy’ was seen for two residents. This gave details of the fee and the rooms to be occupied. The writing on a pre admission assessment done by hospital staff was difficult to read, therefore important information could be overlooked. The senior care worker said that the manager no longer admits people to the home until she has had satisfactory information from the person making the referral. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 10 The home carries out it’s own assessment to determine if needs can be met. The assessments inspected gave more information about immediate needs but there was nothing recorded about peoples’ origins, past life, occupation or interests to direct staff in supporting them to retain existing abilities. The purpose of the home’s assessment is to avoid admitting people whose needs the home cannot meet. Some assessments seen did not show where or when the assessment was carried out. The information in others was very brief and did not record the action planning to prepare for admission. There was information recorded in the body of the care files indicating some forward planning. A person re admitted for respite care had however been reassessed before admission. UCA House DS0000001518.V304778.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality in this outcome area is adequate. This judgement is based on inspection of four care plans, discussion with residents and staff and observation of practices. The personal care observed was overall of a good standard. Staff were able to describe the care each person received but this was not supported by written evidence. The care plans indicated staff lacked confidence and a full understanding of what the care plans were for and how they should be completed. A member of staff confirmed this. The care file pro forma, introduced for consistency had not been completed in a consistent manner. Information, found in the daily records could have been recorded in the care plans to avoid this information being overlooked. Medication practices were not in accordance with the Royal Pharmaceutical Society Guidance and could lead to errors. EVIDENCE: It was apparent from observing and listening to staff speaking to residents that they had been made aware of peoples’ care needs and any restrictions. The written care planning documentation was inconsistent providing better guidance for staff in some files than others. For example, a nutritional UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 12 assessment had been done but a fluid restriction recorded in the daily notes was not written in the nutritional plan where it could be clearly seen. Another file stated the person required a diabetic diet but gave no details of the type of diabetes or its control e.g. by diet, tablets or insulin. One file showed the arrangements for personal laundry, spiritual needs and gave some guidance to staff on how to give emotional support. There was some good recording in the monitoring/ evaluation forms, which showed that the residents, family and key-worker’s views had been considered. A care file discussed with a senior member of staff showed good and relevant care planning but the layout led to the guidance on care being squashed and difficult to read. It is recommended that different care needs be recorded on separate recording sheets. The activities section in one file had not been completed. Closer reading of the daily record said the person attended a day centre but it did not say which one or when. This should have been in the care plan. In another file however the activities sheet had been completed well and showed the person’s involvement in daily routine tasks An inappropriate entry one person’s daily notes did not appear to have been questioned. The manager should introduce a system for monitoring the quality of recorded information, possibly within the supervision programme, to ensure information is relevant and looked at from the resident’s point of view rather than that of the staff. There is a system for assessing the risk of falls followed by a moving and handling plan. This requires more information for it to be effective. For example a moving and handling assessment was undated, said no equipment was needed but did not give guidance to staff on the level of support, if any, that was required. It was recorded in one file that the person had complained of pain and this had been reported to the manager. However, it was not possible to track the care given as there were no further entries to show what action had been taken. One older style of care plan completed in November 05 gave guidance for staff on maintaining continence but not what staff should do when the person refused medication though the senior care worker was able to discuss this. A very pleasant but inexperienced care worker would have benefited from the support of a more experienced member of staff when trying to give the same person assistance with toileting. It is recommended that the care files be more clearly sectioned for consistency and easy access to information. The medication is pre dispensed by the pharmacy but then transferred into daily dosage boxes for administration. This is secondary dispensing which increases the risk of error. The home must follow the Guidance for administration of Medication in Care Homes issued by the Royal UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 13 Pharmaceutical Society of Great Britain to ensure safe medication procedures are in place. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality in this outcome area is good. This judgement is based on inspection of care files and menus, observation and discussion with residents and staff and discussion with a representative of the management committee. There is a relaxed and friendly atmosphere in the home, which gives residents the freedom of choice about how to spend each day. It was good to note that residents are able to assist with routine daily tasks. Families and friends are welcomed and play a part in supporting the social and recreational activities of residents. The menu gives a choice of English and Caribbean dishes which appeared to suit the people spoken with. EVIDENCE: There was a good mix of people living in the home, most mobile enough to move about freely and conduct their lives with some prompting from staff. Several people knew each other before moving into the home and took an active interest in events in each other’s lives. One person was going into town with a relative; another had a visitor who lived nearby and frequently called into the home when passing. One person said a relative did shopping for her and helped to keep her refrigerator stocked. People are encouraged to assist with routine domestic tasks if they wish to help around the home. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 15 Several people continue to attend Frederick Hurdle Day Centre on different days with assistance from their families for transport. Another person had been for an outing to Golden Acre Park. The care files stated religious preferences. One person said the minister visited the home. Care files included a record sheet of activities, though not all had been completed. It was not clear of this was because those people had not done anything social or recreational, or staff had failed to complete the records The atmosphere was relaxed, people who were at home were in their rooms or sitting in the main lounges watching TV or listening to jazz. Later in the day gospel music was playing in the background. One person was seen to go out to the shop for his own cigarettes. The chairperson of the management committee visited and walked around the home talking to staff and residents. She spoke of a garden party, which was arranged for weekend and would be open to the local community. Staff and residents conversed between themselves. There was evidence in daily notes that people played dominoes but showed no provision for bingo which one care plan indicated was a favourite. Most of residents went to the dining room for lunch. The meal was sausage and mash or fried egg and beans. The dining room tables were laid with teapots allowing for extra cups of tea. The cook works until 6pm to allow her to prepare and serve the evening meal. She has started to keep a book in which to record any food which deviates from the main menu. The menus included some Caribbean dishes. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality outcome in this area is good. This judgement has been made from the available evidence which included, speaking to a visitor, looking at the complaints history of the home, speaking to staff, speaking to the manager, inspecting training records and observing practices. The home has made progress in ensuring staff have adult protection training. The organisation is taking action on behalf of those people who are not receiving their entitlement to personal allowance through their families. There must be evidence to show that night staff have had adult protection training and understand the home’s procedures. EVIDENCE: The day staff have had adult protection training since the last inspection but not night staff. One of the staff was able to explain what she would do in the event of an allegation. The manager discussed her concerns that some residents do not receive their personal allowance entitlement from their families to meet their needs. The complaints history shows that the management committee ensure complaints are fully investigated. A book for logging complaints shows how complaints have been resolved. Recent complaints concerned the security of the building. The manager has taken action to increase security for one person without restricting the freedom and rights of others living in the home. It was evident that people felt confident they could bring any complaints to the office and speak directly to the duty staff. One person had complained her television was not working but this was found to be due to a problem across the whole city. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made from the available evidence, which included an inspection of the premises, discussion with staff and residents and observation. The home is well positioned and provides a clean spacious environment with aids and equipment to meet the care needs of residents. Communal areas and bedrooms allow space to meet visitors in private. Action has been taken to manage odour control in the area identified. EVIDENCE: Communal lounges were comfortably furnished. The bedrooms that were seen during a tour of the building were generous in size allowing space for personal possessions and furniture. Each had en suite facilities and all were on the ground floor. The rooms seen had been personalised to suit individual tastes. Moving and handling equipment and bathing aids were provided and bedrails were seen on one bed. Overall the home was clean and free from unpleasant odours. The exception was the first floor landing area where there was a slight odour. The staff were UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 18 able to explain the reason for this and the manager later explained what had been done about it. The management committee carry out routine checks on the home. The chairperson said that they had identified the areas in the kitchen that needed work. Examples were missing tiles and damage to a cupboard door. Some decorative wear and tear was noted in one of the bedrooms. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made from the available evidence, which included, discussion with the staff and residents, examination of staff files and observation of practices. Staffing levels were sufficient for the relatively low care needs of the group of residents. Staff had time to talk to residents and develop good relationships and understanding of their needs. Financial incentives encourage staff to attend training to develop the skills required for their role. The home has satisfactory recruitment ands selection procedure in accordance with equal opportunities. EVIDENCE: There were three care staff, including a senior care worker, caring for 19 residents. The majority were mobile and required little physical support other than prompting. A care worker described most of residents as ‘very cooperative’. The organisation gives an increased pay incentive to people who have the NVQ award. The pre inspection questionnaire showed that ten of the total care team of fourteen have achieved the NVQ level 2 award. A care worker said she had done the 6 weeks ‘fast track’ NVQ programme. One of the care workers had been a member of the home’s bank staff for only two weeks after voluntary work in the home. She had completed NVQ and an induction-training programme. However the manager must ensure new staff UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 20 are supported by more experienced staff to ensure good practices are maintained. The home operates a Key-worker system. A care worker said she has to ensure people have the clothing they need by making families aware of any needs or shopping for items on behalf of the resident. The key-worker is also responsible for making sure the daily records are kept up to date. A staff personnel file was inspected. This showed evidence that all the checks had taken place to protect vulnerable adults. It is recommended that the date and number of returned CRB forms be noted on file as evidence that the results have been seen before a person is appointed. Where references have not been obtained from past care sector employers the reason for this should also be noted. The manager keeps notes of the interviewing process, which were not accessible at the time of the inspection visit. A senior care worker stated that the home operates an annual appraisal system. It was apparent from the two staff files seen that there is a staff supervision system. The content of this was good. However, the dates indicated that supervision does not take place at least 6 times a year as required. The files included a log of each person’s training. A completed fire-training questionnaire was in one file but this was undated. All documents must be dated to ensure people receive updated training when required. It is recommended that the manager keep a ‘master’ training log, which gives an overview of the training and dates when training has taken place. This information is difficult to track when it is spread across separate staff files All day staff have attended Adult protection training. This must be extended to night staff. As part of the home’s Quality assurance system each member of staff carries out and records checks done on the rooms of an allocated group of residents. The staff spoken with felt they had a good team and everyone worked well together. The minutes of staff meetings showed that the manager takes steps to resolve any problems within the staff group. The team meetings are held monthly at the request of the staff to give everyone the opportunity to express their views. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 and 38 The quality outcome in this area is adequate. This judgement is based on the available information which included, inspection of records, information from the pre inspection questionnaire, discussion with a member of the management committee, discussion with staff, an inspection of the premises and observation. The manager appears well respected and gives staff and residents the opportunity to express their views about the home. She has not yet obtained the necessary management qualification but is working towards it. Regulation 26 reports on the conduct of the home were not available and other documentation was not fully completed. Fire safety records and practices were not of a satisfactory standard. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager was at college at the time of the inspection visit therefore senior care staff on the morning and afternoon shifts assisted with the inspection. Both had worked in the home for 3 and 8 years respectively, had NVQ2 and were enrolled on the NVQ3 programme. The chairperson of the management committee who visited stated that the committee members take turns to carry out the regulation 26 visits and report on the conduct of the home. She admitted that circumstances might lead to some visits being missed. It is a requirement that reports of the monthly visits be made available in the home. The manager had responded to requests made by staff for more meetings. The minutes of the monthly meetings showed these to be well attended with good participation by the staff. The manager was described as ‘brilliant, very supportive and fair. A member of staff said that supervision covers training needs. It is recommended that monitoring of care plans be included in supervision to develop staff recording skills and ensure consistency. The following Health and Safety records were inspected: - The fire book showed weekly testing of alarm points but no evidence of routine fire drills. The last recorded fire drill was 7/05 when someone smoking in a bedroom had activated the alarms. The senior care worker was not clear about the arrangements for fire drills and rather vague about the fire evacuation procedures. A tour of the building found a bicycle partially obstructing the fire exit stairs. The evidence raised concerns about what would happen in the event of a fire. It is recommended that someone in the home undertake the approved West Yorkshire Fire Service’s fire trainers course and takes responsibility for fire safety and training in the home. The notifications book provides a record of all events, which may affect the well being of residents. The complaints record included details about the security of the home. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 23 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 3 3 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x x 3 2 2 UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 24 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 OP4 Regulation Reg 15 Requirement Pre-admission assessments must form the basis of a care plan that is in place when residents are admitted and been agreed with the resident and or their relative, so that the home can demonstrate it can meet the needs of the individual. Care files must include enough details to identify each person’s origins and cultural needs. The care files must be consistent in layout and content, with information recorded in a way which allows care to be tracked. Care plans must give clear guidance to staff about health care needs. The administration of medication must meet the Guidelines of the Royal British Pharmaceutical Society. Adult protection training must be extended to night staff to ensure residents are fully safeguarded Timescale for action 30/10/06 2 OP7 Reg 15 31/10/06 3 4 OP8 OP9 Reg 13 Reg 13 31/10/06 30/09/06 5 OP18 OP28 Reg 18 31/03/07 UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 25 6 OP31 Reg 9 8 9 OP37 OP38 Reg 17 Reg 18, 23 The manager must have completed the registered managers award within the expected timescales. This is outstanding from the last inspection Records must contain all the required information The manager must ensure all staff are familiar with the homes fire safety practices and procedures and receive regular recorded fire drills. 31/03/07 31/10/06 30/09/06 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 OP7 OP37 OP38 Good Practice Recommendations Care files should be clearly sectioned to allow easy access to information and aid consistency. It is recommended that the home seek information about the Fire Safety trainers course run by WYFS and enrol someone on the course who will become the fire safety trainer for the home. UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI UCA House DS0000001518.V304778.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!