CARE HOMES FOR OLDER PEOPLE
Dom Polski 18 Carlton Road Whalley Range Manchester M16 8BB Lead Inspector
John Oliver Unannounced Inspection 7th March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 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. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Dom Polski Address 18 Carlton Road Whalley Range Manchester M16 8BB 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) 0161 226 1836 Society of Christ (Gt.Britain) Sandie Maria Deane Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th July 2005 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 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 DS0000021545.V278991.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of 3 hours on Tuesday 7th March 2006. During the inspection time was spent talking to the manager and residents and examining records and care plans. A brief tour of the bedrooms, kitchen and communal areas was also conducted. The last inspection was carried out on the 19th July 2005, when a requirement was made that the home obtain a Criminal Record Bureau check for two members of staff, it was apparent during this inspection that appropriate action had been taken to address this issue. During this inspection only a selection of the key National Minimum Standards were assessed therefore in order to gain the full picture of how the home meets the needs of residents this report should be read with the previous and any future reports. What the service does well:
The manager and staff ensure 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. The home provides a safe and comfortable environment in which to live and there was evidence to show that residents are consulted about day-to-day activities within the home. Samples of the home’s records were examined and were found to be accurate and up to date this enabled staff to provide appropriate support to residents. Several residents who lived at the home described positive experiences of the way staff related to them and spoke of how friendly the staff were. One resident stated, “staff are very kind we are well looked after”. The home had a warm friendly atmosphere and staff were observed to be pleasant and courteous with residents. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 6 The home provided a lot of organised activities and individual activities and at the time of the inspection staff were observed sitting with residents helping to make Easter egg decorations. Throughout the duration of this inspection it became apparent that the registered manager had a visible presence and was approachable to both residents and staff. Residents were observed to stop on their way past the office to say good morning and chat to the manager and all residents appeared to know her first name. One resident said, “ I speak to her every day she is lovely”. This indicated that the manager spent time getting to know the people living at the home. What has improved since the last inspection? What they could do better:
It would be beneficial for the manager to spend some time working in a supernumerary capacity to enable her to fully review the home’s polices and procedures. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 7 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 DS0000021545.V278991.R01.S.doc Version 5.1 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 Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. The home undertakes an assessment of prospective residents’ care needs prior to their admission and they and their relatives/friends are able to visit the home before making the decision to stay. EVIDENCE: The service had a Statement of Purpose and Function and a Service User’s Guide to reflect the staffing and management structure of the home. Both documents were available in English and Polish and would be made available to prospective residents and or their representatives. A pre-admission assessment document is in use and is usually completed prior to admission by the manager or the deputy manager. This is used to ensure prospective residents are only admitted on the basis of a full assessment and that the home is able to meet the individuals needs. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. The registered manager usually carried out the pre-admission assessment.
Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 10 Following the pre-admission assessment, the manager confirmed in writing to the perspective resident that the home was able/ not able to meet their needs in respect to their health and welfare. A copy of this letter was held on the resident’s files. Where possible, prospective residents and their family/representatives were encouraged to view the home prior to making a decision about admission. One resident was asked why they had chosen this particular home and said “a friends mother lived here and she was very happy”. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 The home had arrangements in place to ensure that the health and personal care needs of the residents are identified and met and that their privacy is respected. EVIDENCE: Each resident had an individual care plan that had been developed using information from the Care Management Assessment and the pre-admission assessment carried out by the home. The care plans included a pressure area risk assessment and a nutritional assessment. There was documentary evidence to show that care plans were reviewed on a monthly basis to ensure the changing needs of residents were identified and met. Each resident was registered with a local General Practitioner (GP) where possible residents had retained their own GP. Residents could see their GP in the privacy of their own room. This was confirmed in discussions with residents. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 12 There was evidence to show that residents had been referred to other specialised services according to residents’ assessed needs. This included District Nurses, Dentist, Dietician and Chiropodists. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The home served traditional Polish meals, which were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: The menus had been developed in accordance with residents’ likes and dislikes and appeared to offer a varied, wholesome and nutritious diet. The manager stated that residents were regularly consulted with regard to menu planning. Residents’ spoken to, made positive comments in relation to the quality, quantity and choice of meals served. One resident said “the food is lovely”. The home provided a dining area or residents could have their meals in the privacy of their own rooms if they so wished. A tour of the kitchen was undertaken the area was clean and tidy with a large supply of food stock, including fresh fruit and vegetables. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home had a complaints procedure, which gave residents and or their representatives an opportunity to raise their views and concerns and the home has the policies, procedures and systems in place to protect people from harm. EVIDENCE: Each resident had been given a copy of the complaint procedure. A written record was kept of all complaints made and included details of the investigation and any action taken. The home’s complaint procedure included the address and telephone number of the Commission for Social Care Inspection and the complainant’s right to refer their concerns to the Commission for Social Care Inspection at any stage. There was evidence to show that staff had received training relating to the action to be taken in the event of an allegation of abuse, thus ensuring the safety and well being of the residents. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26 The premises are safe and the home’s environment including the standard of hygiene was well maintained both internally and externally. EVIDENCE: The home had a warm and welcoming atmosphere and felt comfortable and homely. All areas of the home were clean and tidy, tastefully decorated and the furniture was of a domestic nature and of a high standard. There was evidence to show that the home had a programme of routine maintenance and renewal of the fabric and decoration. Two residents spoken to said that “the home is kept lovely and clean”. The home provides attractive, well-maintained grounds with a variety of garden areas and a greenhouse fitted with safety glass, which reduced risks to residents. All garden areas are accessible to residents in wheel chairs. The home provided garden furniture to enable residents to sit in the gardens during the good weather.
Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 16 Resident’s bedrooms were seen to be comfortable and personalised. One resident said “I have a lovely room, it overlooks the garden”. Residents’ bedrooms had been fitted with a privacy lock suited to their capabilities and accessible to staff in emergencies. Residents were provided with a key on request unless a risk assessment suggested otherwise. All rooms had a lockable storage space for medication, money or valuables. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 The home’s recruitment policies and procedures promoted the safety and wellbeing of the residents and the numbers and skill mix of staff appeared sufficient to meet the needs of the residents accommodated. EVIDENCE: A sample of staff files were examined and found to contain all the information and documents listed in Schedule 2 of the Care Home Regulations 2001. The requirement made during the unannounced inspection on the 19th July 2005 relating to the home obtaining a Criminal Record Bureau check (CRB) for staff employed to work in the home had been addressed. Copies of CRB disclosures were held on staff files. Training appeared to be a priority in the home. Each member of staff had an individual training and development programme and staff files also included certificates of achievement. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38 The home had systems and procedures in place, which safeguards and protects residents’ financial interests and the home was seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: There were accurate written records, which included a running balance of all transactions made on behalf of residents, receipts were kept and were available for inspection and safe storage was provided for service users’ money and valuables. The home had a health and safety policy in place, environmental and safe working practice risk assessments had been undertaken. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 19 Fire drills were up to date ensuring staff and residents responded appropriately in the event of the fire alarms being activated. The manager demonstrated a good understanding of what action was required in the event of a fire. None of the fire exits were blocked and there was evidence to show that these areas were checked on a daily basis. There was documentary evidence to show that staff had undertaken various short courses including; Health and Safety, Basic Food Hygiene, Moving and Handling, Fire Safety and Basic First Aid. Gas and electricity testing and a Portable Appliance Test had been undertaken, however, the manager was awaiting the test certificates. Copies of these will be forwarded to the Commission for Social Care Inspection area office. Certificates to demonstrate water systems had been appropriately maintained were seen. The accident record book appeared to be up to date and accurate. Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 20 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 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dom Polski DS0000021545.V278991.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection CSCI, Local office 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
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