Inspection on 18/10/07 for Unity Care

This inspection was carried out on 18th 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Unity Care 29/09/09

Unity Care 10/10/08

Unity Care 15/09/06

Unity Care 30/11/05

Unity Care 17/06/05

Unity Care 09/02/05

Unity Care 23/07/04

Unity Care 26/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Unity Care 90 Gravelly Hill Erdington Birmingham West Midlands B23 7PF Lead Inspector Gerard Hammond Key Unannounced Inspection 18th October 2007 09:30 Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 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 Unity Care DS0000017070.V354487.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 Adults 18-65. 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. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Unity Care Address 90 Gravelly Hill Erdington Birmingham West Midlands B23 7PF 0121 686 4406 0121 686 4406 enquiries@unitycare.co.uk Unity care.co.uk Mrs Sylvia Hamilton 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) Mr Wayne Hamilton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 15th September 2006 Brief Description of the Service: 90,Gravelly Hill is a large terraced style property, lying back from a busy main road close to “Spaghetti Junction” on the M6 motorway. The area is well served by public transport links, with a bus stop immediately outside and rail station close by. The home is registered to provide personal care, support and accommodation for up to three adults who have a learning disability. Staff are on duty at all times and “sleep-in” night cover is provided. There are three bedrooms on the first floor. Bathing facilities and toilets are situated on both ground and first floors. At the front of the house is a communal lounge. There is a bedroom on the ground floor that is currently unoccupied. Towards the back of the house is a dining area leading into the kitchen. Doors from the kitchen give access to the rear of the property where there is a paved area to the side and a steeply inclined lawn to the back. There is limited off street parking at the front of the house, and parking restrictions apply on the road outside. The house sits in an elevated position from the road making access difficult for people with restricted mobility. The most recently available information shows that the range of fees for the home is £637.92-£829.35 per week, but it is recommended that people seek up to date information directly from the care home. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first key inspection in the current year 2007-8. Information was gathered from a number of places to help inform the judgements made in this report. The Manager completed an Annual Quality Assurance Assessment (AQAA). Records were examined, including personal files, care plans, previous inspection reports, staff files, safety records and other documents. A visit was made to the home and the Inspector was able to meet both residents and to talk to one of them, the Manager and three other members of staff. A tour of the building was also completed. Thanks are due to the residents, Manager and staff for their co-operation and support during the inspection process. What the service does well: What has improved since the last inspection? Efforts have been made to meet some of the requirements made at the time of the last inspection. Care plans have been updated. Staff are now making sure that residents are weighed regularly, to help make sure they stay healthy and well. A new lockable metal cabinet has been bought so that medicines can be stored more securely than before. Attempts have been made to make information more accessible, for example by producing policies in an “easy read” format. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information to help people choose whether or not the service is right for them needs to be complete, so that decisions are properly informed. Residents’ strengths and needs are properly assessed and people thinking about using the service can visit and try it out first. Individual contracts need to be updated, so that everyone is clear about what the service should provide. EVIDENCE: There have been no new admissions since the time of the last inspection, and the home still currently has one vacancy. The two people living here have been at the home for a number of years. Information is available to help people make a decision about whether or not the service offered can meet their needs. A Statement of Purpose and Service Users’ Guide are in place as required. At the last inspection it was suggested that the Statement of Purpose should include information about how activities are funded. This remains outstanding. Prospective service users need to know what the arrangements are for social and leisure activities, particularly if these involve additional costs. This should be made clear in the information made available (Statement of Purpose, Service Users’ Guide, sample terms and conditions / contract etc.) so that people are able to make a properly informed decision. It was also noted that individual contracts have not been updated since last year. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 9 Sample checking of residents’ personal files showed that their needs have been appropriately assessed. The last inspection report shows that arrangements are in place to enable people considering using the service to visit and see what is on offer, before making any decision about moving in. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessing are in need of improvement, so that it possible to find important information quickly and easily and to make sure that people get the support they need. EVIDENCE: The personal files of both residents were sampled. Care plans are in place for both people, as required. The care plan format follows a set formula: it was suggested that an index at the front of the plan would make information easier to find. At the time of the last inspection it was recommended that plans should be made more “person-centred”, in keeping with the aspirations of the Government White Paper “Valuing People”. It was noted that one person’s file included some material where person-centred approaches had been used. However, this was undated and there was no indication as to who had completed it. Plans also need to be developed to include people’s agreed goals. There was evidence of this, but it was not possible to see what was happening in relation to goals set. For example, under the heading “Ethnic / cultural” it Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 11 showed “to encourage his ethnic and cultural diversity”, but doesn’t show how this will be done. Goals should have outcomes that can be measured, so that it is possible to make a judgement about whether or not they have been achieved. These should be evaluated when the care plan is reviewed. Though care plans on file were of recent date, it was not possible to see how these had been reviewed. Whole care plans should be reviewed at least every six months, with written records kept, showing the names of people taking part and how decisions have been made. During the course of the visit to the home, residents were observed making choices about what they wanted to do. After going to college for the morning, one resident chose to go and visit his mother at home. The other chose what to have for lunch and then went to his room to relax and watch a film. It is clear that residents can and do make positive choices about what they do and can participate in day to day things around the house if they wish. Care plans are supported with risk assessments and these have been numbered and cross-referenced. Unfortunately, this has not been done accurately. For example the care plan for medication refers to risk assessment 47, but this is about finding the way around the neighbourhood. The care plan for teeth / dentures refers to risk assessment 33, but this is about continence management. It was noted that the last inspection report refers to risk assessment information being muddled, so this appears to be a recurring problem. This needs to be reviewed and cross-referencing done accurately. It is important that anyone reading the plan can locate important information quickly and easily, so that potential hazards are correctly identified and action taken to minimise risks. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is some evidence that people are able to do things they value, be part of the community in which they live and keep in touch with families and loved ones. However, recording of these things need to improve, so as to provide a clearer picture of individuals’ choices and quality of life. EVIDENCE: Both residents were on their way out to day activities when the Inspector arrived at the home on the day of the fieldwork visit. As reported above, following their return that lunchtime, one decided to go and visit his mother and the other stayed at home, so it was only possible to speak at length to one resident. He said that he enjoyed living at the home. He attends college three times a week and also enjoys going to town on the bus to go shopping. When he is at home he enjoys using his “Playstation” and watching DVD’s – he has his own movie collection. He said that he does jobs around the house and that staff help him. He said that he enjoyed a holiday at Skegness with people from the organisation’s other home in Aston. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 13 Recording of activities was sampled. This was fairly minimal: in a period of almost three weeks, the only activity recorded was going to college (four times) and visiting family. Other entries showed “went out for lunch” but didn’t say where, with whom etc. The “tick box” format does not encourage staff to provide much in the way of detail. On a “standard list” of activities “walk” was ticked. The corresponding entry said, “Local shops, went for a drive and enjoyed it”. Typical entries are confined to comments such as “in a good mood”, “had dinner, watched TV, stayed in room”. It is difficult to assess what choices people have been offered or how decisions have been made about what they do from the amount of information these records show. People’s activity opportunities are a prime indicator of the quality of life they enjoy. There should be clear links between individuals’ agreed goals and the things they get to do. Sample menus were seen and provided evidence that people enjoy a good range of foods and a balanced and healthy diet. Records of meals refer to a numbered key on the range of menus, so that the number recorded corresponds with a menu item. It was recommended that records should be written and describe exactly the meal taken. It was noted that Afro-Caribbean food was well represented on the menu options, in recognition of both residents’ cultural background. The size of the home means that facilitating individual choice is easily done. Records showed that during the day residents often chose different things, but tended to opt for the same choice for the main meal in the evening. The resident who was interviewed said that he liked the food and could have whatever he wanted. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s basic care needs are well met, but some improvements are required to the support they receive to make sure that they stay healthy and well. Staff must make sure that people receive their medicines in the right amount and at the right time. EVIDENCE: Direct observations of residents’ grooming and personal clothing provided evidence that they receive a good level of basic care. They also clearly enjoy a good rapport with the staff that support them, and both are obviously at ease in each other’s company. The residents have both lived at the home for several years and the staff team is unchanged for some time, so they have had the opportunity to get to know each other well. One resident said, “The staff here are ok, I get on well with them all”. Both of the residents are male and of Afro-Caribbean origin and the current staff team reflects this, providing them with gender and culturally sensitive support. As noted at the time of the last inspection, health action plan checklists are in place. These are fine as far as they go, but action now needs to be taken to Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 15 develop these further. In keeping with comments passed earlier about general care plans, health action plans need to include some measurable goals and kept under review. One person’s plan showed that it had been reviewed, but this consisted merely of the date the review was said to have taken place. It was not possible to ascertain whether or not any progress had been made. A goal was identified “to become more active and continue exercising” but there was no other information about this. It is suggested that this goal might be expanded to include specific activity such as “go for a 30 minute walk four times each week” (or some other activity agreed with the individual) for example. Evidence was seen of GP appointments and involvement of other health professionals including the Community Nurse and Dentist. It was noted that one person’s plan showed that regular eye tests are required, but there was no record of any optician’s appointments. A previous requirement to monitor and record residents’ weight regularly has now been met. A new lockable metal cabinet has now been purchased so that medication can be stored securely. The home uses the NOMAD monitored dosage system, supplied by a local Pharmacist. The Medication Administration Record was examined: it was noted at the beginning of the visit that there was a gap in the recording for medication scheduled to be given earlier that day. When stocks were subsequently examined, it was clear that the medicine had been given but not signed for by the person who administered it. Action must be taken to ensure that all medication is accounted for at the time of administration, and signed for by the person who gives it at the same time. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that their concerns are listened to and taken seriously. They are protected from abuse, neglect and self-harm so that they feel safe and secure. EVIDENCE: As reported at the time of the last inspection, there is an appropriate complaints procedure in place and this is also available in an “easy read” accessible format. The complaints book was seen: no complaints have been received about this service since the last inspection. The conversation held with one of the residents showed that he is clearly aware of his right to make a complaint. He said that he would be comfortable referring any concerns to the Manager or other members of staff. Records examined at the time of the last inspection showed that staff had received training in the protection of vulnerable adults from abuse. The manager advised that the staff team remains unaltered since then. Conversations with staff on duty showed an appropriate understanding of the issues and knowledge about what action to take in the event of witnessing or suspecting that abuse is taking place. Staff records also show that required checks with the Criminal Records Bureau had been carried out prior to commencement of employment. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy the benefit of living in a house that is comfortable, homely and clean. EVIDENCE: The home is a large terraced house set back from a busy main road close to the Gravelly Hill Interchange (“Spaghetti Junction”) on the M6 motorway. The area is well served by public transport links. There is a comfortable lounge at the front of the house. Towards the back is a communal dining area and the kitchen. On this floor is the (currently) unoccupied bedroom, separate w.c., shower room with further w.c. and the laundry room. On the first floor are the two residents’ rooms and the main bathroom and staff room. Residents’ rooms are comfortably furnished, with personal effects and possessions very much in evidence. There is another room on the second floor, currently being developed as an office. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 18 The house occupies an elevated position from the road. It would not be suitable for people with significant mobility problems. To the rear of the property is an enclosed garden. This is steeply sloped, and does not appear to get much use. There is limited parking at the front of the house, and parking restrictions apply on the road outside. The house is kept clean and tidy and a good standard of hygiene maintained throughout. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by an appropriately qualified staff team that knows them well, so that there is good continuity of support. A current training and development plan is required, so that staff needs can be identified and met. Formal supervision needs to improve so that all staff get the support they need to do their jobs. EVIDENCE: Unity Care is a very family-orientated organisation, and the staff team is reflective of this: the majority of the people working in the home are part of the extended family, though not all. There is normally one member of staff on duty per shift, and the Manager’s hours include some “hands on” care in addition to management responsibilities. As reported above, the staff team is a stable group – information provided in the response to the Annual Quality Assurance Assessment shows that no member of staff has left the team in the last twelve months and that no staff from outside agencies have been used. Residents appear to enjoy a good relationship with the people who support them and staff interviewed had a good understanding of their needs and personal preferences. Half of the team has qualifications at NVQ level 2 or above. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 20 Sample checking of staff records showed that required documentation was in place as evidence of appropriately robust recruitment practice. Files contained job descriptions, completed applications, written references and checks with the Criminal Records Bureau. It was noted that staff records were loosely filed in document wallets. It was recommended that staff files should be better organised, perhaps in ring binders sub-divided into relevant sections (e.g. recruitment, supervision, training and development etc.) so that information could be located easily. Files contained evidence of training (certificates etc.) but it was not possible to assess this properly in the absence of a staff training and development plan. It was recommended that this information be collated on a spreadsheet or chart for ease of reference and future updating. The plan should show, for each individual, training completed and qualifications gained. It should highlight gaps (including “refreshers”) and show when outstanding training is scheduled. It is difficult to see how the Manager can have an effective overview of the team’s training and development needs without an appropriately structured plan. This should be produced and a copy forwarded to CSCI. Sampled files showed that some staff had received formal supervision regularly in accordance with the National Minimum Standard (six times in any twelvemonth period, pro-rata for part-time staff), but this was not true in all cases. Action should be taken to ensure that staff receive formal supervision at appropriate intervals. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager has a good relationship with the people in his care, but some aspects of the overall running of the home need improvement. There is a need to demonstrate how people’s views are taken into account, and to improve record keeping practice. The health, safety and welfare of people living in the home are generally well protected. EVIDENCE: The Manager is appropriately qualified to NVQ level4, and has several years experience working with people who have learning disabilities. Staff report that he is approachable and that he is very supportive. As reported above, record keeping in the home could be better. Daily recording provides minimal information about what residents do and how they Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 22 have been involved in making decisions about their lives. On the day of the fieldwork visit, current care plans had to be printed off the computer for inspection. Personal files could be better organised so that important information can be located quickly and easily. The current cross-referencing of care plans and risk assessments is inaccurate and confusing. Material that is out of date or has been superseded should be archived or destroyed as appropriate. The previous inspection report showed that visits required by Regulation 26 (Care Homes Regulations 2001) are being carried out: these were not assessed on this occasion. It is required that an effective system for monitoring and quality assurance of the service is devised and implemented. This should involve seeking directly the views of the people using the service and using this information to underpin its future development. Consideration needs to be given to how this can be done most effectively. It is suggested that there should be clear links to individuals’ personal goals and whether or not these have been achieved. Similarly, the quality assurance review should show how the service has met its own Statement of Purpose and service objectives. Opinions of relatives, friends, professionals and others could be sought in support of this aim. Information needs to be collated and analysed, and the findings published and made available to interested parties. Safety records were sample checked. The fire alarm and fire-fighting equipment have been serviced. Weekly tests have been carried out on the fire alarm, but it was noted that there was a significant gap in recording of this during the summer months. Temperature tests of the fridge and freezer and water outlets had been carried out as required. Opened packages of food in the fridge were labelled appropriately. Portable appliance testing of electrical equipment had been completed. COSHH items were stored in the designated cupboard, which was secure. Unity Care DS0000017070.V354487.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 Adults 18-65 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 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 3 2 X 2 3 X Unity Care DS0000017070.V354487.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 YA6 Regulation 15(1)(2) Requirement Keep care plans under review to ensure that people get the support they need in the ways they wish. Review risk assessments to ensure that unnecessary risks to service users are properly identified and action taken to minimise the likelihood of occurrence. Make sure that cross-references to care plans are accurate. Ensure that people using the service receive treatment and advice from health care professionals in accordance with their assessed needs Ensure that people using the service receive their medication at the right time and in the right amounts, and that the Medication Administration Record is completed accurately. Prepare a staff training and development plan as indicated in the main body of this report and forward a copy to CSCI. Certificates of all training undertaken by staff must be DS0000017070.V354487.R01.S.doc Version 5.2 Page 25 Timescale for action 31/01/08 2. YA9 13(4) 31/12/07 3. YA19 13(1b) 31/12/07 4. YA20 13 (2) 30/11/07 5. YA35 18 (1c) 31/12/07 Sch2(4) Unity Care 6. YA39 24 available in their individual files. (Not assessed) Devise and put into practice a proper system for reviewing and improving the quality of care provided in the home, showing how the views of people using the service have been taken into account. Publish a report of the findings and make it available to all interested parties. 31/01/08 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 YA1 Good Practice Recommendations Update the Statement of Purpose to show clearly the arrangements for service users’ activities, and identify clearly what the service funds and what people using it may be expected to pay for / contribute towards. Update individual service agreements / contracts to make them clear statements of the responsibilities of all parties concerned, including current information and appropriate signatures. Develop individual care plans using recognised “personcentred” approaches. Set goals with outcomes that can be measured, so that it is possible to tell whether or not these have been achieved. Index plans so that it is easy to locate information quickly. Develop recording of activities to provide greater detail. It should be possible to see clear links between chosen activities and care plans / agreed goals, and to show how choices and decisions about what people do have been made. Ensure that all members of staff receive formal supervision at least six times in any 12-month period (pro-rata for part-time staff) and keep written records of all meetings. Review record keeping practice within the home. Tidy up files and index them, removing old material for archiving or destroying as appropriate. Ensure that records of daily care and support are appropriately detailed. Ensure that records of regular tests of equipment in the DS0000017070.V354487.R01.S.doc Version 5.2 Page 26 2. YA5 3. YA6 4. YA13 5. 6. YA36 YA41 7. YA42 Unity Care home relating to health and safety of people using and working in the service are fully maintained and accurately completed. Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Unity Care DS0000017070.V354487.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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. 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