Inspection on 04/10/07 for UCA House

This inspection was carried out on 4th October 2007.

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

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

Other inspections for this house

UCA House 25/08/09

UCA House 29/08/08

UCA House 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE UCA House 12 Hall Lane Chapeltown Leeds West Yorkshire LS7 3HE Lead Inspector Ann Stoner Unannounced Inspection 10:00 4 October 2007 th 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.V349983.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.V349983.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.V349983.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. 16th April 2007 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 at the front of the home. The manager said the fees that applied at the time of this inspection were a standard rate of £370. 52. More up to date information may be obtained from the home. Copies of previous inspection reports are available in the home. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced and was carried out by one inspector who was at the home from 9.30am to 7.30pm on the 4th October 2007. 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 living there. 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. Survey forms were sent out to people living at the home, their relatives and health care professionals. Information from returned survey forms is reflected in this report. An AQAA (Annual Quality Assurance Assessment) was completed by the home before the visit to provide additional information. During the visit a number of documents were looked at and all areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager and staff. Feedback at the end of the visit was given to the manager. I would like to thank everyone who contributed to the inspection process and to the home for the hospitality throughout the day. What the service does well: The home is well positioned close to the heart of the African Caribbean community giving people the opportunity to remain in close contact with old friends and neighbours. The ethnic diversity of the staff group represents that of the people who live at the home, this gives staff a better understanding of people’s cultural needs. The home respects and values the different cultures of people living at the home and responds by offering options such as choices of English or West Indian food on the menu Bedrooms are spacious and people are able to personalise them with their own belongings. There is a warm and friendly atmosphere in the home, where visitors are welcomed. There are facilities for visitors to stay overnight. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans must be developed further to make sure that all of the person’s care needs are identified and instruction for staff are detailed. This will make sure that care is delivered in a way that meets the person’s needs and takes into account their likes and dislikes. To reduce the risk of mistakes the home must not tamper with medication systems set up by the pharmacist and medication must only be given to people if it has been prescribed for them, and is in a container bearing their name. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 7 The safety and security of people living at the home must be paramount. The home must not allow unrestricted access to and from the home. There must also be sufficient numbers of staff on duty throughout the day. This will make sure that the safety and well being of people living at the home is not compromised. A serious concerns letter regarding this was sent to the registered providers after this inspection visit. To make sure that the home is well maintained and comfortable for people living there a full review of furniture, fittings, bedding and décor must take place. Training for staff in areas such as moving and handling, first aid, food hygiene and health and safety must become a priority. This will make sure staff and people living at the home are safe and that staff have the necessary skills to carry out their work. Routines and practices in the home should be reviewed to make sure that they are in the best interests of people living there and not for the benefit of staff. This will make sure that the rights and choices of people living at the home are not restricted. A full list of requirements and recommendations made as a result of this inspection can be found at the end of this report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. UCA House DS0000001518.V349983.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.V349983.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, 4, & 5. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. People thinking about moving into the home and their family or friends have the information needed to choose a home, which will meet their needs. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The home is in the process of developing an information pack, in large print, that will be available to people before admission. The manager said that this pack will contain the Statement of Purpose and Service User Guide, current fees, how to make a complaint and information about where previous inspection reports can be found in the home. It will also include local bus timetables and a map showing facilities such as the nearest Post Office and different churches or other places of worship. This is good practice. The format of the home’s pre-admission assessment has been amended and now has details of where the assessment took place, the names of people involved in the assessment, the outcome of the assessment and any UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 10 professional input needing to be in place at the point of admission. The preadmission assessment of a person admitted since the introduction of the new format was sampled. Further information in some areas is needed, for example the assessment showed that the person had intermittent confusion but there was no information about the extent of this or of how it affected their life. However overall, significant progress has been made to improve the level of assessment information. Information in survey forms completed by people living at the home show that people felt that they had enough information about the home before they moved in. Everyone said that they received a contract and one person said, “I was given the opportunity to have a look round and given a trial period to see if it was the right place for me.” The home provides care for people from different backgrounds and it employs staff that understand the different cultural needs of people living there. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. People who use the service experience adequate quality outcomes in this area. Care records have improved, but further work is needed to make sure that staff have clear and precise instructions to follow. This will make sure that care needs are not overlooked. The principles of respect, dignity and privacy are not always put into practice. This may affect the quality of life for some people. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Since the last inspection the home has improved the level of detail recorded in care plans. However, more work must be done to make sure that all care plans give staff detailed instructions on how to deliver care in all aspects of the person’s life. A selection of care plans was sampled, and in all there was a good personal profile of the person. There was some good information recorded such as, UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 12 ‘Can wash her own hands and face, but cannot wash the rest of her body, staff will need to do this.’ and ‘Put a wash bowl in front of her on a trolley to give her some independence.’ However, some plans needed more information. For example, there was no information about how often one person had a bath, how often she had her hair washed and the type of toiletries she preferred. Another person had a care plan for managing diabetes, which said, ‘Staff to check and record blood sugars three times daily. Needs a diabetic diet to control blood sugars.’ There was no specific information about what constituted a diabetic diet, where blood sugars were recorded, the normal range for blood sugars, what staff should do if the blood sugars were outside of the normal range and the signs and symptoms of hypoglycaemia. Staff described the religious needs of one person and said that he enjoyed gospel music, and liked his Bible and religious things in his room, but he did not have a care plan for religion and culture. The home has now developed nutritional and falls risk assessments. One nutritional risk assessment showed that the person had no nutritional risks. However, she was a diabetic and needed her food cutting up, which should have reflected some degree of risk. Care plans are now reviewed and the new format allows for comments from staff, the person living at the home, their relatives or other significant people and by other professionals. The review of one person showed a good monthly evaluation of GP visits, saying that the person was visited by her GP, her blood pressure was good but she had a slight heart murmur. It also included information about blood samples that had been taken to monitor her kidney function, and that she would be attending the eye clinic in a couple of months. Such level of detail is good practice. Overall, in surveys returned by people living at the home people said that their needs were met but one person said, “I feel that my needs are not taken into account and when I say something nothing is done.” From discussions with staff it was clear that they were aware of the needs of people from different cultures, particularly in relation to personal care and grooming. Records showed evidence of GP (General Practitioner), Optical, Chiropody and community nurse visits to the home. The manager said that wherever possible people moving into the home are able to keep their own GP. Following the last inspection the home has bought a new drug trolley and medication is recorded at the time it is administered. The home uses a Nomad system for medication, which is dispensed by a local pharmacist. A record of what the pharmacist has dispensed is on each person’s Nomad pack. One Nomad pack had Co-Codamol that had not been dispensed by the pharmacist. The manager said that staff at the home had added these tablets to the Nomad. This is unsafe practice and is unacceptable. Inside the drug trolley bottles of medicine were sticky and were sticking to the trolley. There was a UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 13 packet of Co-Codamol without a pharmacy label and the manager could not explain why these tablets were in use. This is poor practice. When ordering repeat prescriptions the home does not keep a copy of the original order. This means that there is no sure way of checking the prescription against the original request; therefore errors may not be detected. Handwritten entries on Medication Administration Records (MAR) did not always specify the amount of medication received, and the entries were not checked and countersigned by a second person. A member of staff who administered the lunchtime medication followed proper procedures. All bedroom doors have a letterbox so people can have their mail delivered. The manager said that this increased the level of privacy and dignity offered to people. Staff were seen knocking and waiting for permission to enter people’s rooms. As identified at the last inspection the call system allows conversations in people’s rooms to be overheard. The manager said that quotations are being obtained for a new call system to be fitted. Incontinent pads were in use in some lounge chairs, which is undignified. When someone has a continence problem an individual continence programme eliminates the need to use such institutional and undignified measures. UCA House DS0000001518.V349983.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. People who use the service experience adequate quality outcomes in this area. The cultural and religious needs of people are respected, but the amount of activities available to people is restricted by staffing levels. This leaves some people with little to keep them occupied. Staff routines restrict and limit the amount of choice available to people, thus making an impact on their quality of life. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The home has a policy for religion and culture which addresses issues such as fasting, clothing, dietary needs etc. In returned survey forms staff felt that they met the cultural needs of people living at the home well and gave examples of assisting with grooming, dressing and food preparation according to individual beliefs and/or culture. During the inspection a priest visited to give communion and later in the day a volunteer held a small service in one lounge. People joining in appeared to enjoy this informal service. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 15 Meetings are held for people living at the home, but the minutes of these meetings show that this is a forum for people to express their views about their care, which is more of a review rather than a consultative process. There was no evidence in the minutes to show that people are informed and consulted about any changes in the home such as refurbishment, changes to menus or new staff. This is an area that should be developed so that there is a two-way system of information sharing between staff and people living at the home. Although staff said that people living at the home have a range of choices and are encouraged to make decisions, they then described routines that are more task orientated than person-centred. For example, one carer said that most people are assisted to have a bath on a morning, and went on to say that she had assisted six people to have a bath the previous morning. She said that she found it easier to bath someone rather than assist them to wash, and that staff preferred using the bath to the shower. People were served a midmorning drink and although tea and coffee was being served people were not asked which drink they preferred. When asked about this the care worker said, “I know what people want, I have served them more than once.” All of this limits and restricts the choices that people make. People were offered a choice of meal at lunchtime, but because there are no menus displayed, they did not know what food was on offer until it was served. This means that sometimes they have to make a quick decision, although staff were patient with people and showed both options so people could make a choice. Menus show that cultural foods are served and on some days people have a choice between English or West Indian meals. The main meal is served in the evening with a snack at lunchtime. The lunchtime meal was soup and sandwiches or sausage, beans and bread and butter, followed by yoghurt or fresh fruit. The dining room is basic. The furniture is scuffed and plastic tablecloths along with drinking water decanted into 2 litre juice bottles create an institutional feel. The manager said that there are plans to replace the flooring, furniture and table linen in this area. A notice board displayed the daily activities, which included floor games, exercise, tabletop games, bingo, quiz, craft and reminiscence sessions. During the afternoon some people took part in a game of dominoes. Survey forms completed by people living at the home were inconclusive regarding the suitability of activities. Some people thought that the activities provided were suitable, whilst others did not. As can be seen later in this report, staffing levels restrict the amount of time they have to spend with people and it is difficult to see how staff have time to spend with people, particularly those who remain in their rooms, rather than sitting in the communal lounges. Throughout the day there was a constant stream of visitors to the home and all were made welcome. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 16 UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. People who use the service experience adequate quality outcomes in this area. Unrestricted access to and from the building places people at risk. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Returned survey forms completed by staff show that they know what to do if anyone has concerns about the home, and returned survey forms completed by people living at the home show that they know how to make a complaint. However, an additional comment in a survey form shows that one person feels that even though staff listen to people, things do not always get done. There is a complaints procedure displayed on a notice board in the entrance of the home, but this is inaccessible for people in wheelchairs and because it is not in large print, some people are disadvantaged. The manager said that information packs, which are being developed, would address some of these issues. Since the last inspection the manager has developed a new system for recording complaints and there has been none recorded. One person’s care records showed that her daughter had made a complaint about a person giving her fruit and food away to staff. The manager dealt with this properly but this had not been recorded. The manager was reminded that all complaints, however small, should be recorded, along with any action taken. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 18 On more than one occasion there have been incidents of people being missing from the home, having left the building unnoticed by staff. During this inspection the front door of the home was not secure and allowed unrestricted access to and from the building, thus placing people living there at risk. This is unacceptable and a serious concerns letter has been sent to the providers. Staff described the different types of abuse and were confident about the action they should take if they suspected any safeguarding (abuse) issues. The manager has a date planned to attend safeguarding training, so she will then be able to train other staff in the home. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 & 26. People who use the service experience adequate quality outcomes in this area. A full review of the home’s furniture, fittings, bedding and décor is needed to make sure that it is well maintained and comfortable for the people living there. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Since the last inspection bedroom doors now close when the fire alarm system is activated. However, wooden door wedges were still being used to prop open the office door and the kitchen door leading into the dining room, which poses a risk in the event of a fire. Several parts of the home are in need of refurbishing and decorating. One bedroom has been converted into a small smoking lounge. This room looked unattractive, there was wallpaper coming off the walls, picture hooks on the walls without any pictures, there were three UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 20 uncomfortable hard back chairs, and no towels or soap in the adjoining ensuite toilet. Some bathrooms had skirting boards with paint peeling off and exposed pipe work, a shower room had a gap in the floor covering between the toilet and shower, some bedrooms had wallpaper peeling off the walls, no paint on the window frames and windows that were dirty. There are plenty of signs around the home, helping those people with some degree of memory loss to find their way about the home. People are able to personalise their rooms and furnish them according to personal taste, but some bed linen needs replacing. Several rooms had pillows that were badly stained, one counterpane was torn, one bed had a blanket and counterpane but not a top sheet, and other beds had a duvet but no top sheet. Not everyone in one lounge could see the television; some people were squinting to see it. A large amount of toiletries was stored in bathrooms, which not only poses a health and safety risk but also suggests communal use of toiletries. Staff later confirmed this. Used and soiled incontinent pads were not double wrapped before being placed in clinical waste bins, which meant that there was an offensive smell whenever the bin was opened. 50 of the staff team have completed training on infection control and the manager said that training on hand washing is to take place soon. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. People who use the service experience adequate quality outcomes in this area. Staffing levels do not always meet the needs of the people living at the home, which means that at times their needs may not be met. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Information in the AQAA (Annual Quality Assurance Assessment) completed by the manager before this inspection shows that the ethnicity of the staff group reflects that of people living at the home. There is a mixed age group of staff and a mix of full and part time workers. 20 of the staff team are male. The manager said that one person at the home prefers female care workers to deliver her personal care and this is respected. Throughout the day there are 2 care workers plus one person in charge of the shift on duty. In addition to providing personal care staff carry out some household tasks, such as making beds and doing the laundry. This means that if one carer is assisting someone to bathe and the other is doing laundry, supervision of people living at the home is left to the person in charge of the shift. Staff said that this was not a problem because some people go out to a day centre and others remain in their rooms. Comments like this suggest that people in their rooms have little interaction, support and supervision from staff, other than at times when personal care is being delivered. During the inspection there were times when people in their rooms and people sitting in the communal lounges were left UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 22 unsupervised and as identified previously in this report there have been occasions when people have left the building unnoticed by staff. The AQAA, completed by the manager, states that the home could do better by adapting duty rotas to provide more staff at busy times. Comments in returned survey forms completed by people living at the home include: • • There has been a lot of use of agency staff and my needs are not always tended to. I have noticed that the level of care and support varies depending on which staff are on duty. There has been a lot of agency staff used over the last few months, with regular staff not being on duty. This has concerned me, particularly during the evenings and night as some agency staff do not fully understand or appreciate my needs. Since the last inspection the home has developed an induction programme that is based on the Skills for Care common induction standards. The home has prioritised NVQs (National Vocation Qualifications) in the training and development programme for staff. Whilst this is good practice, it has been at the expense of mandatory training such as moving and handling, basic food hygiene, health & safety and first aid. The AQAA shows that there are 15 permanent staff, 13 of whom have completed an NVQ level 2 in Care and the remaining 2 are currently being assessed. Not all staff have had food hygiene training, and moving and handling and first aid was last carried out in 2004 and is well out of date. There is no system in place to show when mandatory training updates are needed. The recruitment records of two people was sampled. employment checks had taken place as required. All the necessary pre- UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38. People who use the service experience adequate quality outcomes in this area. Management standards are improving but some practices compromise the health and safety of both staff and people living at the home. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Since the last inspection the manager has completed the Registered Manager’s Award. The manager said that she now has some days that are supernumerary to the rota but without the support of a full time deputy she still does many shifts working on the rota, which means she has little or no time to carry out her management duties. Although further work is needed to make sure that the home meets the National Minimum Standards for Care Homes for Older People, the manager has made significant progress since the UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 24 last inspection. She has a better understanding of the Care Homes Regulations 2001 and her improving IT (Information Technology) skills are helping her access information from the Internet that is relevant to the running of the home. In returned staff surveys comments included: • We are always given up to date information and the staff and manager work together to make our service better. We work as a team. • • An effective and fully staffed management team must support the manager in order to allow her to continue the home’s development. The manager said that the home is in the process of employing external consultants to carry out a quality assurance audit. A member of the United Caribbean Association now carry out regulation 26 visit reports. Whenever the home holds money for people living at the home a record of the transaction is kept. However, receipts for the transactions are not always obtained and some records of transactions are not clear. The possibility of this leading to financial abuse was discussed with the manager. The AQAA shows that equipment is serviced and maintained as required. The manager analyses accidents on a monthly basis to identify any patterns or trends, but where accidents in the home are not witnessed by staff a record of when the person was last seen and by whom is not always made. As identified previously in this report the health and safety of people living at the home is compromised by unauthorised access to the building and by people leaving the home unnoticed by staff. CSCI (Commission for Social Care Inspection) was not informed that one person had been missing from the home, and although a written notification was sent about another missing person, this was not reported verbally at the time. The manager was reminded of her responsibilities under Regulation 37 of the Care Homes Regulations 2001. Not all staff have had health & safety training and mandatory training updates are not carried out as required. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 25 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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 2 X 2 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 2 X 2 X 2 X X 1 UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 26 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 OP7 Regulatio n 15 (1) Requirement People using the service must have an up to date, detailed care plan. This will ensure that they receive person centred support that meets their needs. The home must not add any medication to Nomad packs that have been dispensed by a pharmacist. Medication must not be administered unless it has been prescribed, dispensed and labelled with the individual’s name. This will make sure proper procedures are followed and eliminate the risk of mistakes. 13 (4) (c) The home must not allow unrestricted access to and from the building. This will make sure that people living at the home are safe. 16 (2) (c) A full review of the home’s 23 (2) furniture, fittings, bedding and (b) décor must take place. This will make sure that the home is well DS0000001518.V349983.R01.S.doc Timescale for action 31/12/07 2. OP9 13 (2) 05/10/07 3. OP18 05/10/07 4 OP19 31/12/07 UCA House Version 5.2 Page 27 5. OP27 18 (1) (a) maintained and comfortable for people living there. There must be sufficient numbers of care staff on duty throughout the day. 31/12/07 6. OP30 This will make sure that the safety and well being of people living at the home is not compromised. 18 (1) (c) All staff must have training in food hygiene, first aid, health & safety and moving and handling. Training updates must take place as required. This will make sure that staff have the necessary skills and knowledge to carry out their work. 31/12/07 7 OP35 17 (2) Where the home holds money on behalf of a person living at the home, receipts must be kept of all transactions. This will reduce the risk of financial abuse. The Commission for Social Care Inspection must be notified, without delay, of any event that affects the well being of people living at the home. 05/10/07 8 OP38 37 05/10/07 9 OP38 13 (4) (a) This will make sure that the home is complying with the Care Homes Regulations 2001. Doors must not be wedged open. 05/10/07 This will ensure the safety of people in the event of a fire. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 28 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 assessment information should be in enough detail to form the basis of a care plan. This will make sure that the home can meet the person’s needs and that staff have the necessary information about the precise level of care the person needs. When ordering repeat prescriptions the home should keep a copy of their request. This system will make sure any mistakes are identified and rectified. Handwritten entries on Medication Administration Records should specify the amount of medication received, and the entry should be checked and countersigned by a second person. This will reduce the risk of errors. Incontinent pads should be removed from lounge chairs. This will promote the dignity and privacy of people living at the home. The emergency call system should be updated or replaced. This will make sure that people’s privacy is respected. The home should consider recruiting more staff so that people have access to recreation and leisure activities suited to their past and present interests and abilities. Routines and practices in the home should be reviewed to make sure a person-centred approach is adopted. This will make sure that the choices of people living at the home are not restricted. The home should consider ways of making sure people are aware of the daily menu before each meal is served. This will enable people to take time to choose their meal. When not in use toiletries should be returned to the person’s room. This will reduce any health & safety risks and eliminate communal use of toiletries. Used and soiled continence products should be double wrapped before being placed in the clinical waste bin. This will eliminate offensive smells and reduce the risk of cross infection. The manager’s duty rota should be reviewed so that she has dedicated management time. DS0000001518.V349983.R01.S.doc Version 5.2 Page 29 2. OP9 3. 4 5. 6 OP10 OP10 OP12 OP14 7 8 OP15 OP26 9 OP31 UCA House 10 OP38 This should improve the management of the home. If an accident is not witnessed a record should be made of when the person was last seen and by whom. UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI UCA House DS0000001518.V349983.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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