Inspection on 25/04/07 for Jasna Gora

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Jasna Gora 28/11/06

Jasna Gora 07/02/06

Jasna Gora 06/09/05

Jasna Gora 03/02/05

Jasna Gora 23/09/04

Jasna Gora 04/03/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Jasna Gora 52 Fixby Road Fixby Huddersfield West Yorkshire HD2 2JQ Lead Inspector Tracey South, Helen Battle Unannounced Inspection 25th April 2007 09:15 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 Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jasna Gora Address 52 Fixby Road Fixby Huddersfield West Yorkshire HD2 2JQ 01484 451850 01484 469473 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) Society of Christ (Great Britain) Mrs Anna Szczesna Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2006 Brief Description of the Service: Jasna Gora is a well-maintained home offering care and accommodation for up to twelve, predominately Polish, older people. It is an attractive house set in large, accessible and well-maintained grounds and situated in a quiet position off the main road. There is a bus route nearby. There is a lounge, a dining room, eight single bedrooms and two double bedrooms. There are five toilets and two bathrooms. There is a passenger lift in situ which serves the ground and first floors. There is a chapel within the home where religious services take place on a daily basis, for those residents who choose to participate. Information provided by the home prior to the inspection indicated that the fees range from £331.26 to £342.99 per week. Additional charges are made for, hairdressing, chiropody, magazines, newspapers, transport and activities. The service provider ensures that information about the service is available to prospective residents and the current residents by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection the Commission for Social Care Inspection (CSCI) undertook a visit to the home. The manager was given a day’s notice that the visit would take place on 25th April 2007. Alongside this, the staff at the home also completed a pre-inspection questionnaire, which was returned to the Commission before the inspection as requested. Information from this questionnaire was also used for this report. Two inspectors carried out the site visit. The inspectors arrived at the home at 9.20am and left at 3.20pm. Surveys were sent to ten people who live at Jasna Gora including their relatives and one GP. Ten surveys were sent out to residents, eight were returned. Nine surveys were sent out to relatives, five were returned. One GP survey was sent which was completed and returned. In writing this report, information and evidence was not only obtained by way of visiting the home, but also from notifications sent and information obtained by Commission for Social Care Inspection. The last inspection report was also consulted. Care practice was observed throughout the day. One inspector spoke to one person living at the home who speaks English and Polish. Discussions also took place with the manager and the Assistant Executive Administrator for the Society of Christ who visited the home at the same time as this visit. Records were examined and a tour of the home was also undertaken. There were 11 residents living at the home on the day of the inspection. And the inspectors would like to thank everyone for their assistance and hospitality during the inspection process. What the service does well: Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 6 Prior to new people moving into the home their needs are thoroughly assessed by the manager, to ensure that Jasna Gora will be able to meet their needs. People are able to visit the home in order to help them make a decision as to whether or not it is the right home for them. The Statement of Purpose and Service User Guide provides good information about what people can expect at Jasna Gora. People at the home are treated with the utmost respect. The atmosphere at the home is warm and friendly and visitors are made to feel very welcome. Staff were observed providing care to people in a discreet and sensitive manner particularly when supporting them with feeding. People request to live at Jasna Gora because they know their cultural and spiritual needs will be met. The home benefits from having its own chapel which people are able to use as they wish. Food at the home is traditionally Polish and surveys returned by people who live at the home indicated that they like the meals provided. One lady who is able to speak English told one of the inspectors how she enjoyed living at the home. She spoke positively about the staff saying they were kind to her. Comments received from people who returned surveys to the Commission included, “I am satisfied with my stay at Jasna Gora”. “I like the Polish food served at the care home”. “I receive everything that I need at my age and in my current state of health”. “I don’t have any complaints, I am satisfied with everything”. “I am pleased with the fact that I can spend the last days of my life among Polish people and that I receive the care I need”. Relatives were asked in surveys, what the home does well. as follows: People responded “Ethos hits you – it is really warm and friendly. Residents are respected and cared for. Staff are interested in the individual. It is a happy atmosphere. Central to everything is the happiness and well-being of the resident. Staff very welcoming to visitors. True family atmosphere”. “From the moment of walking into the home, you can sense a very warm family atmosphere which is as a result of the staff that work there. They treat everyone with love one would reserve normally for one’s own relatives. This love, combined with the respect shown to the residents – and each other is the result of a wonderful care home”. “This is unique and well run home. I could not wish for any better for my mother”. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Standard 6 does not apply. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: In response to the last inspection report both the Statement of Purpose and Service User guide have been amended and now provide prospective residents with the information they need to make an informed choice about whether or not Jasna Gora is the home for them. All new and existing residents have recently received a new and up to date contract of residence. The contract informs people of the services they can expect to receive including what is and is not included in the fees. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 10 The manager and staff have worked hard since the last inspection in November 2006 to ensure that prospective residents only move into the home following a thorough pre-admission assessment. The manager has implemented a new assessment form to use in respect of new people wishing to move into the home. Three completed assessments were examined, all of which contained detailed information about each person’s needs. With this information in place, and information provided by the funding authority, the manager is then able to make an informed decision as to whether the home can meet the person’s needs. Only then will the prospective resident be offered a place at the home. All three residents’ surveys indicated that people received enough information about the home prior to them moving in which helped them to decide that Jasna Gora was the right home for them. The manager explained that prospective residents and their relatives are invited to visit the home prior to the person moving in. There are circumstances when this is not possible, particularly when people are moving in straight from hospital. The manager said that more often than not it is the relatives who visit the home on behalf of their loved ones. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The level of care people need, which includes their health, personal and social cares needs are clearly highlighted within their care plan. EVIDENCE: Surveys returned to the Commission for relatives indicated that the home is meeting peoples’ needs. Comments include, “Medical needs are fully met. Allowed her independence but supported in the areas she needs support. Spiritually her needs are fully met. Socially – Mum says the community is ‘one big family’”. “Very caring staff who are ALL so sincere and genuinely put the needs of ALL the residents as their first priority”. “The home meets the needs of elderly Polish people. They have the opportunity to choose to attend daily Mass, daily Rosary etc.” There is a marked improvement in the care records now in place from when the home was last inspected. The staff team are to be commended on the Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 12 amount of work they have undertaken in ensuring that all care records are relevant and up to date. The care records of three new people were examined. Care plans contain detailed information about the person’s needs and the level of support they require. There is an action plan in each person’s record, which illustrates, at a glance, the help and support they require. This is particularly useful for those staff who may need to get a quick insight about a person before having the chance to get to know them better whilst at the same time trying to offer them the right level of support. Reviews of care plans take place each month and the information recorded as part of the review, is very good. It is clear from the detail recorded that the manager has carried out a thorough review of each person’s care throughout that particular month. People who have lived at the home for some time, accompanied by their next of kin, have been invited to take part in the review of their care plan. Evidence of letters sent out to relatives were seen during this visit. Surveys returned to the Commission include comments made by people living at the home, such as, “I am very satisfied with the care I receive at the care home”. “I receive the help I need, but I try to be independent in everything I do”. Each resident is registered with a local GP. Records of medical visits including the GP, district nurse, optician and chiropodist were seen in residents’ care records. The GP survey returned to the CSCI indicated that people appear to be well cared for. The GP did comment that it is difficult to talk to staff in English but that the Manager can be contacted if the matter is urgent. Residents’ surveys indicated that the majority of people felt their medical needs are met. Issues were raised as part of the last inspection about people’s health care needs not being followed through and the associated documentation was not up to date. Documents such as Waterlow Assessments (used to identify those prone to developing pressure sores), dietary and weight assessments are being used much more effectively. It was pointed out to the Manager that these could be further developed by ensuring that as much detail as possible is recorded for those people who have developed a pressure sore. Ensuring that details about the treatment and current condition of the sore is also included. Staff are responsible for writing a daily report about how each person has been throughout the day, evening and night shift. The daily reports examined have improved although many are repetitive. Staff need to focus on writing about how they have met people’s needs in accordance with the care plan. The home has policies and procedures in place referring to the safe keeping and administering of medication in both English and Polish. Medication records Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 13 examined were found to be neat and tidy and easy to follow. Two peoples’ medication was examined; one administrative error was noted otherwise the medication was correct. To help protect people living at the home from medication errors there is a list of authorised signatures in place, which clearly details the staff who are responsible for administering medication. Staff were observed treating people with respect. The manner in which they approach people is kind and caring and the atmosphere at the home is warm and friendly. Despite the inspectors not being able to speak the Polish language it was clear from people’s body language that they were happy and well cared for. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Polish language, culture and traditions are observed and people are positive about their life at Jasna Gora. EVIDENCE: People have requested to live at Jasna Gora to fulfil their cultural and spiritual needs and this appears to be the ethos of the home, as well as providing good quality care to vulnerable people. The staff speak Polish as do the people who live there, and a few people are able to speak a little English. Staff are currently undergoing English speaking lessons to help them communicate better with relatives and other professionals. The manager speaks fluent English and assisted the inspectors greatly in providing information about the home, individual people, and the staff. Comments received from relatives include, “Although Holy Mass and the rosary are said daily, these are optional. Residents should they wish, can have own TV’s and phones in their rooms. Nobody is forced to do anything they don’t want to. You couldn’t wish for a better care home”. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 15 Since the last inspection six staff have received training on ‘Moving More Often’, the purpose of the training is to encourage people at the home to be more active and in turn increasing their independence. The manager said the training has been well received in terms of more people becoming actively involved in activities or simply doing more for themselves. On the day of the visit a group of people were playing bingo. Staff were supporting those who needed help and everyone appeared to enjoy the game. Two surveys returned by people at the home said there are “usually” activities arranged by the home that they can take part in; one person said there was “always” something arranged. The home benefits from having its own chapel and people are able to take part in Mass and Rosary each day at their own choice. There was evidence in the daily reports that people have joined in the Easter celebrations, decorations were also evident around the home symbolising the importance of Easter for people living at Jasna Gora. Relatives are able to visit the home at any reasonable time. There were no visitors at the home during this visit. The inspectors were invited to a traditional Polish meal of beetroot soup, meat and/or blueberry pasties with sauerkraut and pears in juice. The meal was delicious and well presented. Although the majority of people had already taken their meal before the inspectors joined the staff with theirs, one person was observed being given help and support by staff. She was helped in an appropriate manner, which was discreet and dignified. She was allowed plenty of time to finish her meal that she appeared to enjoy. People’s likes and dislikes are recorded in their care plan including any special requirements they may have. Surveys returned to the Commission indicated that people like their meals. Comments received include, “The Polish meals prepared are tasty”, “I am satisfied with the meals prepared at the care home (Polish cuisine)”. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident that their complaint will be dealt with effectively and that they are protected from abuse. EVIDENCE: The complaints procedure has been updated since the last inspection informing people of when they can expect their complaint to be dealt with, that is, within 28 days. The home has not received any complaints since the last inspection but has received a number of compliments about the quality of care provided. Returned surveys indicated that people who live at the home know how to make a complaint and who to speak to if they are unhappy about something. Comments received include, “I do not have any complaints, I am satisfied with everything”, “I have no reason to may any complaints”. Four out of five relatives indicated they know how to make a complaint about the care provided by the home. A requirement was made in the last inspection report that the home’s adult protection policy must be updated to reflect the Department of Health guidance on safeguarding vulnerable people. This has now been addressed and staff are directed to refer to the local authority’s policy and procedures of how to report allegations of abuse. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 17 The manager has undertaken a ‘train the trainers’ course, which enables her to deliver training on adult protection to the staff at the home. There was good evidence that the training she delivers is detailed giving staff an insight into the different forms of abuse and the reasons why and how they speak out about poor practice. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers people a safe, clean and homely place to live. EVIDENCE: When entering the home the atmosphere at Jasna Gora is warm and welcoming. All areas of the home were immaculately clean. There were no unpleasant odours present in any parts of the home. Responses from surveys said that people felt the home is “always” fresh and clean. Two people made the following comments, “In my opinion the house is kept clean and the staff takes a great deal of concern about the cleanliness every day”. “The care home’s staff cares a lot about the tidiness. This is why it is so clean and tidy”. The gardens are very well maintained and make a perfect place for people to sit out when the weather is suitable. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 19 The Manager explained that the local authority has invited care homes to submit an application for a grant to use on upgrading the interior and exterior of the home. The home has submitted their application to upgrade parts of the building as well as requesting monies to purchase items such as garden furniture. A tour of the home was carried out which included looking at a number of bedrooms. People’s bedrooms have been personalised by the occupant, which gives them a ‘homely’ feel. The manager was advised to replace two commodes, which were rusty. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are met by trained and qualified staff who have undergone a thorough recruitment process before they are allowed to work in the home. EVIDENCE: Returned surveys indicate that staff are available when needed and that they listen to people and act on what they say. There are currently eleven residents living at the home and the staffing levels are, two care staff on the day shift and one care staff at night, with a second person on call. The care staff are supported by kitchen and cleaning staff. The manager works 37 hours per week during normal office hours. One member of staff has achieved NVQ level 2 qualification in care and one person is working towards it. Further progress has been made in that 4 staff are due to start working towards achieving NVQ 2 next week. And a further 2 staff are due to start NVQ level 3 the following week. Domestic staff are to due to commence NVQ level 1 in housekeeping shortly. A requirement was made in the last inspection report due to shortfalls in the documentation obtained in respect of new staff working at the home. Without evidence such as pre-employment checks in place the home is not able to Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 21 demonstrate that they have carried out a thorough recruitment process leaving the people that live there potentially at risk. However, since then the home has taken the CSCI’s comments on board and the three staff files examined contained the correct documentation such as, Criminal Records Bureau (CRB) checks, POVA (Protection of Vulnerable Adults) 1st checks and two written references. New staff undertake induction training in accordance with the ‘Skills for Care’ Common Induction Standards, within their first 12 weeks of employment. Other training taken place since the last inspection includes, Manual Handling, Vision Call training, Adult Protection and Fire Training. Certificates of attendance were seen in the staff files examined. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and people are not only kept safe by good health and safety practices, they are also involved in making improvements as part of the home’s quality assurance system. EVIDENCE: The manager at Jasna Gora is Mrs Anna Szczesna who is also a registered nurse. Ms Szczesna has worked at the home for over 3 years and is experienced and competent in looking after vulnerable people. She has recently achieved the Registered Manager’s Award. Mrs Szczesna speaks both Polish and English and therefore she is able to communicate effectively to people who live at the home as well as their relatives, other professionals and of course the staff. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 23 The CSCI both acknowledges and congratulates Mrs Szczesna and her team on the hard work undertaken and the progress made in addressing the issues brought about during the last visit to the home in November 06. Quality assurance questionnaires were given to people living at the home in March 2007. The results of which were collated and a report published. People submitted their ideas on improving things in the home and the management has welcomed their ideas. Questionnaires were recently sent out to relatives and as soon as responses are returned a report on the findings will be published. Relatives were asked as part of the survey how the care home could improve. Responses received include, “Less paperwork and form filling, more time for patients”. “The home has put in place English language lessons for staff where needed”. “How can you improve on 100 ”. “They could possibly have facility for treatment room that could also be used as doctors/dentist/chiropodist surgery?”. The Assistant Executive Administrator is now responsible for carrying out monthly management visits to the home. The purpose of the visit is to form an opinion of the standard of care provided in the home as well as checking documentation. To date two such visits have been completed and the Commission have been sent copies of the management reports. Small amounts of monies are kept on behalf of residents. Families are responsible for handling residents’ financial affairs. Two people’s monies were checked both of which were correct in accordance with records kept. The manager meets with staff as part of their supervision. Records in place suggest that the majority of staff have received supervision every 3 months. The sessions allow the manager and staff to discuss all aspects of care practice as well as career developments. The manager undertakes comprehensive health and safety audits to ensure the health and welfare of residents and staff. There was good evidence of monthly audits undertaken. The fire alarm system is checked weekly, that includes, electrical applications, doors, escape routes, fire extinguishers, emergency lights and the nurse call system. The most recent fire drill to take place was on 14th March 2007. The fire risk assessment has recently been reviewed and updated due to a person living in the home smoking. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 3 X 4 Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 25 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. 1. 2. 3. Refer to Standard OP8 OP19 OP28 Good Practice Recommendations Waterlow Assessments should include more detail about the pressure sore, including the current treatment, equipment used and a general progress report. The two commodes in Rooms 2 and 5 need replacing. The home should continue working towards achieving 50 of the staff being qualified at NVQ level 2 in care. Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Jasna Gora DS0000038443.V332479.R01.S.doc Version 5.2 Page 27 - 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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