Inspection on 19/07/05 for Dom Polski

This inspection was carried out on 19th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dom Polski 12/03/07

Dom Polski 07/03/06

Dom Polski 09/11/04

Dom Polski 29/06/04

Dom Polski 17/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dom Polski 18 Carlton Road Whalley Range Manchester M16 8BB Lead Inspector John Oliver Unannounced 19 July 2005 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 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. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dom Polski Address 18 Carlton Road Whalley Range Manchester M16 8BB 0161 226 1836 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Society of Christ (Gt Britain) Responsible Individual - Rev W. Pajak Sandie Maria Deane Care home only 14 Category(ies) of Old age, not falling into any other category (OP) registration, with number (14) of places Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9 November 2004 Brief Description of the Service: Dom Polski is a large detached property that provides accommodation for 14 elderly residents requiring personal care only. The home provides a specialist service for elderly Polish people. The home is owned and operated by the Fathers Of The Society of Christ (Great Britain) a Polish religious organisation and a registered charity. The home is situated in a residential area in the south of the City of Manchester. Local facilities and bus routes are within easy walking distance. The garden area is accessible to residents and was extremely well maintained and presented. Parking facilities are available to the rear of the property. The Polish language, culture and traditions were upheld within the home. The home impresses as being clean and comfortable, and having a family atmosphere despite the fact that it caters for up to 14 residents. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 19th July 2005 over a four and a half hour period. The inspection involved spending time talking with the manager, the responsible individual, staff on duty at the time and a number of residents who wanted to say how they found living in the home. Some time was spent looking at files, records and the home’s policies and procedures. The inspector also had a look around the inside of the home as well as having a walk around the outside of the building. At the last inspection, which was done in November 2004, no improvements were identified to be carried out. However, at this inspection, one improvement was noted that needed to take place, and this has been identified in this report. Not all standards were checked at this inspection and it is strongly advised that this report should be read together with the last inspection report and any future inspection reports to get a full picture of how the service is meeting the needs of the residents living there. What the service does well: The manager and staff team of the home have worked hard to provide residents with a comfortable and safe place to live. Watching staff at work gave a good indication of their commitment to providing residents with a pleasant atmosphere in which to live. A lot of time has been spent in making sure that individual residents get support in the way that is most important to them. The Polish culture and traditions are part of the everyday lifestyle for people living in the home. Residents are encouraged to take part in making decisions about how they would like to spend their day. Good record keeping is seen as important by the manager. Those records seen during the inspection were well written, accurate and, up to date. This enabled staff working in the home to supply support to the residents to a high standard. During the inspection a nurse visiting the home wanted to say how she found the service being offered to people living there. She said, “it does not matter Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 6 when you visit, the home is always the same, no unpleasant smells, well run and a pleasure to visit” and, “why can’t all homes be like this one?” Talking with two particular residents the inspector was told that “everything is very good”, “meals are wonderful”, “choice is offered”, “the manager talks to everyone” and, “staff are respectful”. What has improved since the last inspection? 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. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 and 6 Prospective residents were being assessed prior to admission into the home. Trial visits to the home were made available to enable an assessment of the suitability of the services being offered to a potential resident. In addition, prospective residents were given significant information about the service being offered prior to admission. EVIDENCE: The service had updated the Statement of Purpose and Service User’s Guide to reflect the new staffing and management structure of the home. Both documents were available in English and Polish. These documents would be made available to anyone interested in coming to live at Dom Polski. The file of a resident recently admitted to the home was examined. It contained all relevant information including copies of the pre admission assessments. Also on file, was a letter sent by the manager, confirming that the home could meet her needs following the assessment carried out. Information also gave a clear indication that the resident had used “trial visits” to the home to help her make a choice about where she wanted to live. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 9 Observing the interaction between residents and staff and discussion with residents and staff indicated that the home was able to meet the needs of the residents currently accommodated. Healthcare professionals from other agencies were seen to visit individuals in the home during the inspection. Case notes also indicated regular and consistent interaction from healthcare professionals. This information helped to confirm that the needs of residents were being met at the time of this inspection. Dom Polski does not offer the service of intermediate care and the manager confirmed this. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Resident’s health and social care needs were being met and their privacy promoted and respected by the home. EVIDENCE: Care plans and risk assessments had been completed for each resident living in the home. These were comprehensive in content and gave clear guidelines to staff in how to support the person to meet their identified needs and goals. Nutritional and pressure sore risk assessments had been completed for each resident and, along with the care plan, were reviewed on a monthly basis. Wherever possible the resident had signed all relevant documents. Medication was appropriately administered and information was readily available to support any resident who may be responsible for their own medication. This information was available in both English and Polish. A number of residents spoken to confirmed that they were able to see their doctor or other healthcare professionals in the privacy of their own rooms. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 11 This was evidenced during the inspection when a health visitor called. The manager telephoned the resident in her room and the resident came to deal with the visitor, and, took her to her room. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Residents have choice and support to meet their expectations and preferences regarding their daily lifestyle. EVIDENCE: The routine of the home was very relaxed and informal. Residents had opportunity to spend time socialising in communal areas or in the privacy of their own rooms. A number of rooms seen during the inspection gave clear indications that the residents who occupied these rooms had been given support to participate in activities of their choice and, in the privacy of their own rooms. During the inspection a number of visitors came into the home and were welcomed with tea and biscuits by the staff. The inspector had opportunity to speak with a visitor who was the daughter of one of the residents. Feedback about the home, the service and the staff was extremely positive. Menus were planned with the full involvement of the residents. Evidence of meetings held every month to discuss meals and menus was available for inspection. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The homes complaint policies and procedures was known to the residents who were aware of who to discuss any concerns with. EVIDENCE: A record of complaints was kept. No complaints had been recorded since the inspection conducted in November 2004 and the manager confirmed that no other complaints had been received. The Commission for Social Care Inspection had received no complaints. Discussion with two residents demonstrated that they were clear about how and who to make a complaint to. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25 and 26 The general environment of the home was clean, tidy and comfortable with systems in place to protect the safety of residents. EVIDENCE: Evidence available indicated that routine renewal and maintenance of the home was on going. Appropriate risk assessments were in place where required. Bedrooms viewed during the inspection were clean, comfortable and personalised to varying degrees reflecting the character of the resident. The manager had carried out an audit of each room to ensure that the contents of the rooms met the individual requirements of the resident. This information was contained on the individual residents’ file. The bathroom and toilets were sufficient in numbers to meet resident needs. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 15 Laundry facilities were sited in the basement of the home and were found to be extremely clean, tidy and very well organised. Laundry was transported via colour coded laundry bags to prevent the spread of infection. Water had been checked to prevent the colonisation of Legionella and a certificate to confirm this was available. Externally, the property was very well maintained. The gardens were well kept, safe and accessible to residents. Since the last inspection, the rear garden had been ‘cultivated’ and various vegetables planted. A new greenhouse had been installed, and, it is commendable that this has been fitted with ‘safety’ glass. This was to ensure those residents who enjoyed gardening and growing plants could use this facility with minimum risk. New benches, tables and umbrellas had been provided for residents to enjoy sitting outside on days when the weather is good. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home’s recruitment and training policies and procedures were in place and provided enough details to support the employment of sufficient well trained staff. However, Criminal Record Bureau checks had not been completed for all staff employed in the home therefore placing residents at risk. EVIDENCE: The staff team in the home consisted of the registered manager, 9 care staff of which 4 belonged to a Religious Order and 5 ancillary staff. The staffing rota reflected that enough staff had been deployed throughout the week to meet the needs of the residents living in the home. The staff rota included the staff names and hours worked. The high standard of cleanliness in the home indicated that sufficient domestic staff was employed. The files of two staff employed in the home were checked. All documentation relating to employment was found to be on file. However, neither employee had a relevant Criminal Record Bureau check in place. This could place residents and other staff at risk. This was discussed with the manager and the responsible individual for the home. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33 and 38 People living in the home benefit from having a manager with the management skills to provide a quality service and the home has systems in place to help people express their views, opinions and influence change in the service they receive. EVIDENCE: Through discussion it was clear that the registered manager had a good understanding of the conditions and illnesses that are associated with old age and was able to address such issues quickly, benefiting the residents. Her background also clearly demonstrated that she had the knowledge and skills to provide a service that was also culturally appropriate. Residents were involved in the monthly house meeting where issues affecting the house were discussed and actions agreed. Senior management were provided with the minutes from these meetings and would be used as part of Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 18 the quality assurance process and the development of an annual plan for the organisation. A health and safety policy was in place and risk assessments of the premises and safe working practices had been carried out. This was to ensure that both residents and staff had relevant information to enable them to live and work in relative safety. Relevant certificates were on file to show that appropriate servicing of equipment used by residents in the home had been carried out. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 3 x x x x 3 Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 20 no Are there any outstanding requirements from the last inspection? 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 29 Regulation 19 Requirement Criminal Record Bureau checks (including POVA) must be obtained for those staff not yet checked. Timescale for action 30th September 2005 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 Good Practice Recommendations No recommendations have been made as a result of this inspection. Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 9th Floor, Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dom Polski F55 F05 s21545 Dom Polski V239880 D190705 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!