Care Home: UCA House

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What the care home does well People who live at UCA House are satisfied with the care they receive and are involved in making decisions about their lives. People are offered a varied and nutritious diet. People enjoy the food and are happy with the quality of meals. People receive good support with their personal care needs. People live in a clean, tidy and comfortable environment. What the care home could do better: Care plans and risk management plans should continue to be developed to make sure people using the service have an up to date, detailed care plan. This will make sure that people receive person centred support that meets their needs. Medication administration records should contain all the relevant information for administering medicines and be accurately completed. This will make sure people who live at the home are given medicines as the prescriber instructed. A more robust system for handling people`s finances on an individual basis must be introduced. This will make sure people`s monies are safeguarded. Staff should receive more training that equips them with the right knowledge, understanding and skills. This will help make sure everyone who lives and works at the home is safe. The home should have better management systems in place. A manager should be recruited and given sufficient time to carry out management tasks. The organisation should make sure copies of reports about the running and conduct of the home are kept at the home. This will help management at the home monitor the quality of the service. Random inspection report Care homes for older people Name: Address: UCA House 12 Hall Lane Chapeltown Leeds West Yorkshire LS7 3HE one star adequate service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Carol Haj-Najafi Date: 0 3 0 6 2 0 1 0 Information about the care home Name of care home: Address: UCA House 12 Hall Lane Chapeltown Leeds West Yorkshire LS7 3HE 01132626537 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Manager Post Vacant Type of registration: Number of places registered: Conditions of registration: Category(ies) : United Caribbean Association care home 19 Number of places (if applicable): Under 65 Over 65 19 0 old age, not falling within any other category physical disability Conditions of registration: 0 2 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. Date of last inspection Brief description of the care home 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 Care Homes for Older People Page 2 of 11 Brief description of the care home specialises in providing care for people predominantly but not exclusively from an African Caribbean origin, with a staff group that is representative of the ethnic origins of the people who live at the home. Accommodation, with communal lounges, dining room and bedrooms, is over three floors. There is a passenger lift to assist people unable to climb stairs. The home has reduced the total number of beds to 19 because one bedroom has been made into a smoking room for people living there. All of the 19 bedrooms have en-suite facilities. There is a small car park and garden at the front of the home. The home should be contacted directly for up to date information about fees. Copies of previous inspection reports are available in the home. Care Homes for Older People Page 3 of 11 What we found: We looked at all the information that we have received, or asked for, since the last inspection. This included: - The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. - Information we have about how the service has managed any complaints or safeguarding incidents. - What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. - The previous inspection which was carried out on 24 August 2009 and annual service reviews. - Relevant information from other organisations and what other people have told us about the service. Surveys were sent out to people who live at UCA House. Seven surveys were returned to us and everyone had help from a relative or staff to complete the survey. We have included some of the survey comments in this report. Two inspectors carried out an unannounced visit to the home on 3rd June 2010. We spent four hours and forty minutes at the home and spoke to six people who live at the home, three staff, and the deputy manager who is temporarily managing the home on a day to day basis. We looked around parts of the home, and at care plans, medication systems, staff training records and personal finances. In the AQAA, when asked what the home does well, the acting manager said, Maintain residents health and ensure they have access to all care services to meet all assessed needs. Provide staff with background knowledge and skills to meet the needs of our residents. Friendly atmosphere for residents and staff. In the AQAA, the acting manager provided good information about how equality and diversity are promoted and incorporated into what they do, and said, Religious and cultural needs are catered for through diet and prayer meetings. Sunday services are arranged in house for those not able to go out to church. Holy communion is offered by the local church once a month. Religious, cultural and spiritual needs are included in peoples care plans. We also seek outside resources to meet the equality and diversity of each individual such as a befriending service, local community events, day centres and luncheon clubs. People we spoke to during our visit told us they are generally content living at UCA House and are well cared for. One person said, Ive no complaints, the food is excellent, there are enough staff on duty and theyre kind to me. Another person said, The staff are friendly . Another person said, Here is alright for me. Ive never found fault since I Care Homes for Older People Page 4 of 11 came here. People who live at the home said they make decisions about what they do, for example, deciding when to go to bed and when to get up on a morning. One person said. I go to bed when I want. I do what I want. People said they get support with their personal care and healthcare professionals visit the home when they need them. One person said, I see a GP whenever I need one. Staff also said the home is very good at meeting peoples personal care needs. In the AQAA the acting manager said, Residents are encouraged to attend day centres, churches, social and leisure activities and cultural interests. This is done to help maintain their social contacts and well-being. When asked what they could do better, the acting manager said, Promote more activities suitable to the residents request. Be persistent with activities provided. Encourage residents to take part in activities being offered but remembering they still have a choice to refuse. Five surveys from people who live at the home said the home arranges activities; two left the question blank. Some people said they have enough to do; one person said they would like to do more. Staff said they try to encourage people to do different things but it is often hard to motivate people. When asked what the home does well, two staff said they have opportunities to spend time chatting to people, which everyone enjoys. At the last inspection we said the home must keep an accurate record of the medication received into the home so that medication can be checked properly and any errors easily identified. They have introduced a medication stock control system, and count and record any medication they receive. Medication was administered appropriately at lunch. The staff member made sure people had a drink and told people that she was administering medication. We looked at the medication administration records (MAR). Most were printed by the pharmacist; one persons MAR was handwritten by the home. CQC have guidance that says printed MAR charts are not essential but they are better than handwritten charts. This is because there is less risk of error. But if a handwritten MAR is the only available option, there must be a robust system to check that the MAR is correct before it is used. The home does not have a robust system in place. Only one staff member checks to make sure the information is correct. The hand written MAR did not contain all the information that was recorded on the prescribers instruction. For example, information about administering before or after food was omitted. Some medicines were spelt incorrectly. We also found some gaps in the medication records. At the last inspection we said they must have effective systems and record keeping must be put in place to make sure peoples money and valuables are properly safeguarded. This will make sure people are not at risk from financial abuse. We looked at personal monies that are held on behalf of people living at the home. Handwritten internal receipts are used for the amount of money taken out rather than receipts obtained when items are purchased. The acting manager explained that money is usually taken out and put together collectively to buy toiletries for everyone. For example in April 2010, £5 was taken for each person amounting to £45. A shop receipt for 43.64 showed that toiletries were purchased but there was no way of determining what had been bought for each individual. The acting manager keeps a bag of money where they add the change from each collective shop. At the last inspection we said the television in the lounge must be repaired or renewed. People said the television worked satisfactorily and it had a clear picture when we were at Care Homes for Older People Page 5 of 11 the home. We looked around some parts of the home. All areas were clean and tidy and appeared to be well maintained although some rooms showed signs of wear and tear. The acting manager identified in the AQAA that some areas of the home need decorating but said the programme is currently on hold due to financial circumstances. At the last inspection we suggested the care plans and risk management plans should continue to be reviewed to make sure people using the service have an up to date, detailed care plan. This will make sure that people receive person centred support that meets their needs. We looked at four peoples care plans and risk management plans at this inspection. Some information in the care records was good and gave detailed information about how how their needs should be met and how potential risks should be minimised. Other information was inaccurate and some important information was missing. For example, one persons monitoring sheet said a community mental health nurse had visited them once a month but their care plan did not contain any information about mental health problems. Another persons care plan said they walk with a stick but we observed them walking with a frame. The acting manager has started introducing lifestyle choices and action plans, which are being completed with the people who live at the home. They cover peoples likes, dislikes, preferences and life history. In the AQAA the acting manager told us about improvements they are planning over the next twelve months, and said, New manager. Training in mandatory courses, dementia, diabetes, care planning. The acting manager has reviewed the training needs of all staff and identified that some training has not been updated within the agreed timescale. The home does not have a clear plan for how and when training needs will be addressed. The homes medication policy states that staff will receive medication training at least annually. The staff training records identified that two staff completed training in 2009, one staff completed training in 2008 but four staff had not completed training since 2006. Seven staff have not completed safeguarding training since 2006 and four staff have not received any safeguarding training. Two staff received safeguarding training in 2007, one staff received in 2008; two in 2009 and one in 2010. Staff told us people receive a good service at UCA House. One staff said, People get very good care. They eat properly, have a good, healthy diet and get good support with personal care. Another staff said, We sit and chat with people and find out if theyre happy. The acting manager acknowledged that some management tasks have not been completed because they do not have a manager in post. Staff are not receiving supervision and some paperwork is not being completed. For example accident records dating back several months had not been checked and filed. The home is advertising for a new manager. The acting manager works on shift and does not have specific management time. The committee for the home meets on a monthly basis and the chairperson visits every week to discuss the running of the home and to meet with people who live at the home. A report about the running of the home should be written at least every month. The acting manager could only find one report which was dated March 2010. What the care home does well: Care Homes for Older People Page 6 of 11 People who live at UCA House are satisfied with the care they receive and are involved in making decisions about their lives. People are offered a varied and nutritious diet. People enjoy the food and are happy with the quality of meals. People receive good support with their personal care needs. People live in a clean, tidy and comfortable environment. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 11 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 8 of 11 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Medication administration 31/07/2010 records must contain all the relevant information for administering medicines and be accurately completed. This will make sure people who live at the home are given medicines as the prescriber instructed. Staff must receive more training that equips them with the right knowledge, understanding and skills. This will help make sure everyone who lives and works at the home is safe. 31/07/2010 2 30 18 3 35 13 A robust system for handling 31/07/2010 peoples finances on an individual basis must be in place. This will make sure peoples monies are safeguarded. Care Homes for Older People Page 9 of 11 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Care plans and risk management plans should continue to be developed to make sure people using the service have an up to date, detailed care plan. This will make sure that people receive person centred support that meets their needs. The home should have a registered manager in place. This will make sure the home is properly managed. Reports on the general running and conduct of the service should be kept in the home. This will help make sure the management of the home can monitor the quality of the service. 2 3 31 33 Care Homes for Older People Page 10 of 11 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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