Inspection on 28/11/06 for Jasna Gora

This inspection was carried out on 28th November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Jasna Gora 25/04/07

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 Irene Ward Key Unannounced Inspection 28th November 2006 09:40 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.V314644.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.V314644.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.V314644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 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.V314644.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. 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. One of the inspectors speaks Ukrainian and was able to communicate with the residents and staff in their first language. The inspectors arrived at the home at 9.40am and left at 3.20pm. Surveys were sent to residents, their relatives and GPs. Twelve surveys were sent out to residents, eight were returned. Eleven surveys were sent out to relatives, six responses 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 during the day. The inspector spoke to a number of residents and a visiting relative. Discussions also took place with the manager and care staff. Records were examined and a tour of the home was also undertaken. As part of this inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. There were 11 residents living at the home on the day of the inspection. The inspectors would like to thank everyone for their assistance and hospitality during the inspection process. Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Twelve staff have received adult protection training. Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 7 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.V314644.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.V314644.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 and 3. 6 does not apply. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information about the home prior to them moving in, although they are not routinely given a copy of their contract or statement of terms and conditions. Not all residents are being properly assessed prior to moving into the home. EVIDENCE: One inspector examined the home’s Service User Guide and Statement of Purpose. Both documents were available in Polish and English, although the daily routines in the English version were not the same as the Polish version. The Manager needs to ensure that both documents offer the same information, for example, the arrangements for attending Mass. In the summary section of the Statement of Purpose it states that Jasna Gora is a care home for Polish elders. This is not entirely correct as there are people Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 10 living at Jasna Gora who are not Polish. The Statement of Purpose should be amended to reflect this. The inspector spoke to two residents who had recently moved into the home. Both confirmed that they had received a copy of the Service User Guide prior to moving in, although there was no written evidence of this in the residents’ care records. There was evidence in the two residents’ care records that they had been notified about the cost of their care. There was no evidence in either record examined, that the resident had received a contract of residence. Although surveys returned to the Commission indicated that the majority of residents had received a contract. The manager should ensure a copy of the resident’s contract with the home, or the funding authority, is kept on file. The second inspector examined a further two residents’ care records, one of which did contain a contract of residence that included the relevant information. Although it did not state who was responsible for payment of the fees. The issues in respect of the Service User Guide, Contract of Residence and the Statement of Purpose must be addressed and requirements and recommendations have been made to ensure residents receive the information they require prior to and once they have moved into the home. The inspectors examined four residents’ care records in total. Only one contained information to confirm that the resident had been properly assessed prior to moving into the home. The assessment record in place had been received from the funding authority and included an outline of the resident’s assessed needs. None of the other three care records contained any information about the prospective residents’ assessed needs. The manager did confirm that she had visited these people prior to them moving into the home but she made no record of the visit. The purpose of carrying out a pre-admission assessment is to ascertain the needs of the prospective resident which will assist staff to make a decision as to whether or not the home will be able to meet those needs. The information gathered as part of the assessment process should then be used to form the basis of the initial care plan. Jasna Gora DS0000038443.V314644.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all residents have a care plan in place that details their needs and the level of support they require. Residents have access to health care services but there is a lack of evidence that health care needs are followed through. Residents are protected by the home’s medication procedure. Residents are treated with dignity and respect. EVIDENCE: Eight residents who responded to the survey said they always receive the care and support they need. Four residents’ care records were examined in detail. One inspector examined the records of two residents who had been admitted to the home within the last two months. Neither had a completed care plan. Sections of the care plan had been completed such as the moving and handling and risk assessment but they lacked sufficient details. For example, risk assessments were not detailed Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 12 enough in how the home manages specific risks. The manual-handling plan did not mention how the person would be supported with bathing. The second inspector examined a further two care records. The care plans were complete and generally of a good standard. However, the results of monthly health care assessments have not been included in the care plan. Residents who are at risk of developing pressure sores must have a plan that states what care is needed to monitor skin condition and prevent sores. One resident whose weight was being monitored, had lost 7kg in a month. There was no record as to why this may have occurred or that a referral to the GP had been made. When examining the medical records for the same resident, it was noted that they attended an outpatient’s appointment at the skin clinic, but there was no information within the file to explain why. The manual handling assessments do not include the weight and height of the person. This needs to be rectified, as without this information, a proper assessment of how to manually handle the person cannot be done. The assessment should also include any other handling constraints to consider that may affect how the person is supported. 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. Residents’ surveys indicated that the majority of people felt their medical needs are met. The one GP survey returned to the Commission indicated that the home communicates clearly and work in partnership with the GP practice. The GP also said that they are able to see their patients in private although there is not always a senior member of staff to confer with. The survey also indicated that this GP practice was satisfied with the overall care provided to residents within the home. The home has policies and procedures in place referring to the safe keeping and administering of medication. Medication records examined were found to be neat and tidy and easy to follow. There is a list of authorised signatures in place, which clearly detail the staff who are responsible for administering medication. Stocks of medication brought forward from the previous month could not be easily reconciled with records. Greater care must be taken to ensure that all medication kept at the home easily reconciles with the medication records. One relative’s survey included the following comment, “staff treat residents with dignity and respect. Staff always extremely polite to all residents and visitors”. Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 13 Jasna Gora DS0000038443.V314644.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make their own choices about how they spend their time and are encouraged to maintain contact with their relatives and friends. Jasna Gora offers meals in the Polish culinary tradition. EVIDENCE: The Polish language, culture and traditions are observed. All staff at the home speak Polish. Residents were seen reading Polish newspapers. Polish television and radio is also available. The manager explained that residents are able to spend their time as they choose. Some residents take part in Rosary and Mass in the home’s chapel. One resident was seen walking in the gardens of the home. The manager explained that four staff have recently attended a briefing session on activities in the care home. The staff will receive training on how to introduce gentle exercises within the home in order to keep people mobile. Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 15 Residents were asked as part of the survey if there are activities arranged by the home that they are able to take part in. Six people said always, one person said, sometimes. Residents are encouraged to maintain contact with their relatives and friends. Visitors are welcome at any reasonable time during the day or evening (10am8pm). One inspector spoke to a visiting relative who gave positive feedback about the home. She said she couldn’t fault the home, and that she would like to book herself a place for when the time comes. Six relatives surveys were returned to the Commission. All of which said they were made to feel welcome in the home. They also confirmed that they are able to visit their relative/friend in private. All surveys said yes, they were kept informed of important matters affecting their relative/friend. The manager explained that residents are able to choose how they spend their day. The majority of residents were sat in the lounge area watching television. The meals are in the Polish culinary tradition. Residents spoke positively about the meals at Jasna Gora. One resident said, “the food is very good, always plenty of it”. Comments made in the residents’ surveys included, “All the meals are very tasty”. “All the meals are very good”. One visitor said that her relative had gained weight since moving into the home. The inspectors were invited to join the staff for a meal. The meal was very good. Surveys returned to the Commission indicated that 7 people liked the meals at the home. One person said they usually did. Jasna Gora DS0000038443.V314644.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives can be assured that their complaints will be acted upon. Residents are protected from abuse. The documentation in respect of complaints and adult protection is not up to date. EVIDENCE: The complaints procedure is available in both Polish and English. The procedure is displayed in the front entrance of the home. Slight amendments are required to the current procedure in order to inform people that their complaint will be responded to within a maximum of 28 days. The home has not received any complaints within the last 12 months. During the last inspection the manager was advised to document as and when she deals with concerns and informal complaints. To date this has not been put into action. Residents receive a copy of the complaints procedure as part of the Service User Guide before they move into the home. Two residents were asked if they felt they have all the information they need to make a complaint about their care. The two residents said they did and that they would speak with either the staff or the manager if they were unhappy about something. Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 17 Since the last inspection 12 staff have received adult protection training. The home has also received a Polish version of “how to report abuse of vulnerable adults” leaflet produced by Kirklees MC. A requirement was made in the last inspection report that the home’s adult protection policy must be revised to ensure it meets with Department of Health guidance. This has not been completed and therefore the requirement is repeated. Staff explained that they are learning about protecting people as part of the induction training. Jasna Gora DS0000038443.V314644.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Jasna Gora offers a safe, homely and well-maintained environment for residents. The home is clean, pleasant and hygienic. EVIDENCE: Jasna Gora has a warm and welcoming atmosphere. All areas of the home were clean and tidy. There were no unpleasant odours present in any parts of the home. The home benefits from having its own chapel. Residents are able to take part in Rosary and Mass if they choose to. Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 19 One resident kindly showed the inspector around her bedroom. The bedroom had been personalised with the resident’s own belongings. There was a privacy screen in place as the bedroom was a shared room. The home provides attractive and well-maintained gardens. One resident was seen walking around the gardens during the morning of the inspection. The manager explained that weather permitting, staff will happily escort residents on a short walk around the home. The environmental health officer last visited the home in June 2006. Three recommendations were made as a result of the visit, all but one has been addressed. The manager should ensure that the outstanding recommendation is addressed. Jasna Gora DS0000038443.V314644.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are enough staff on duty to meet the residents’ needs. Residents are potentially at risk as the home’s recruitment process is not thorough enough. Staff receive the training they require to undertake their jobs effectively. EVIDENCE: As part of the relatives’ surveys, people were asked whether, in their opinion, there are always sufficient numbers of staff on duty. Five relatives said yes, one relative said no. All six relatives said they were satisfied with the overall care provided at the home. There are currently eleven residents living at the home and the staffing levels are, two or three 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. The manager is an NVQ Assessor and explained that one member of staff has achieved NVQ level 2 qualification. A further two staff are working towards their award. Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 21 Four staff personnel files were examined, only one file contained the information and documents required in accordance with the Care Home Regulations 2001. Without this information in place the home cannot demonstrate that they have undertaken a thorough recruitment process. And therefore residents could be potentially put at risk. The manager must ensure that two written references are obtained prior to the new member of staff starting work. New staff must only be confirmed in post following completion of a satisfactory police check and against the protection of vulnerable adults register. The manager should refer to Schedule 2 of the Care Homes Regulations 2001 in order to ensure each staff file contains the relevant documents. Information provided to the commission prior to the inspection taking place indicates that the staff have received the following training; protection of vulnerable adults, continence, manual handling, fire and an English speaking course. Seven staff have enrolled to undertake the New Common Induction Standards. Further training in manual handling and health and safety is planned for December 2006. Residents’ surveys asked if staff listen and act on what they are told, seven residents said yes they did. They were also asked if staff were available when needed, eight people said they always are. One resident said “I like all the staff very much”. Jasna Gora DS0000038443.V314644.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, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is run and managed by a person who is fit to be in charge. The home is run in the best interest of the residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The registered manager Anna Szczesna is a competent and experienced individual who is respected amongst her peers. Ms Szczesna demonstrates compassion and a genuine desire to look after older people. She is currently undertaking the Registered Manager’s Award and plays a vital role in supporting staff through their training. Training providers offer training in the Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 23 home but as the staff speak Polish and very little English, Ms Szczesna is responsible for translating any dialogue, as well as written information, for the staff. This is very time consuming and takes up an enormous amount of her time. Quality assurance questionnaires are given to residents for completion on a yearly basis. Evidence of this was seen during the last inspection at the home. The manager explained that questionnaires are due to be sent out in January 2007. In accordance with Regulation 26 of the Care Homes Regulations 2001 the organisation, Society of Christ (Great Britain) must appoint an individual to carry out monthly visits to the home. The visit must include speaking to residents, staff and relatives in order to form an opinion of the standard of care provided in the home. An inspection of the building including records of events and complaints must also be carried out. A report on the conduct of the home must then be produced, a copy of must be available to the Commission for Social Care Inspection. A requirement was made to this affect as part of the last inspection report but to date this has not been addressed. Small amounts of monies are kept on behalf of residents. Families are responsible for handling residents’ financial affairs. Residents’ personal monies were not checked during this inspection. The home undertakes comprehensive health and safety audits to ensure the health and welfare of residents and staff. The fire alarm is checked on a weekly basis and the most recent fire drill was on 29th August 2006. Accidents involving residents are appropriately recorded. Information provided to the Commission for Social Care Inspection indicates that equipment is serviced on a regular basis. The manager was unclear as to when the emergency call system was last serviced. She was advised to look into this and report back to the Commission with the details. Jasna Gora DS0000038443.V314644.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 2 1 1 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 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 Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 3 Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5,6 Requirement Information in the Statement of Purpose and Service User Guide must be current and up to date. Both the English and Polish versions must contain the same information relevant to residents. The resident must receive a copy of the terms and conditions in respect of accommodation to be provided including as to the amount and method of payment of fees. All prospective residents must be thoroughly assessed prior to moving into the home. All residents must have a care plan in place that is completed in full. The care plan must include the care needs of the resident and the level of support they require. The manager must be able to show evidence that the resident and or their representative has been involved in the writing up of the care plan. Risk assessments must contain sufficient detail of how risks will DS0000038443.V314644.R01.S.doc Timescale for action 30/01/07 2 OP2 5 30/01/07 3 4 OP3 OP7 14 15 30/12/06 30/01/07 5 OP7 15 30/01/07 6 OP8 13 30/01/07 Jasna Gora Version 5.2 Page 26 7 OP8 13 8 OP8 13 9 OP8 13 10 OP16 22 11 OP18 13(6) be managed. Pressure care assessments must include information about the equipment used to promote tissue viability and prevention of pressure sores. Manual handling assessments must clearly identify the weight height and any other behaviour that may affect the safe handling of residents. The assessment must also include specific details of the level of assistance and equipment required, such as when bathing. Identified health care needs such as weight loss must be dealt with appropriately and a record of this must be made in the resident’s care records. The complaints procedure displayed in the front entrance must be updated to include the timescale of when the complaint will be dealt with, that is, within 28 days. The home’s adult protection policy must be revised to ensure it meets with Department of Health guidance. Requirement repeated as timescale of 30.03.06 not met. 30/01/07 30/01/07 30/12/06 30/01/07 28/02/07 12 OP29 19 13 OP33 26 Required pre-employment 30/01/07 checks must be carried out on all staff. Recruitment records must include a CRB check and two written references. A representative from the 30/01/07 organisation must carry out monthly visits and prepare a report on the conduct of the home. A copy of the report must be sent to the CSCI each month. Requirement repeated as timescale of 30.03.06 not met. DS0000038443.V314644.R01.S.doc Version 5.2 Page 27 Jasna Gora 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 OP9 Good Practice Recommendations Staff must take greater care when using the brought forward system in order to make sure all medication tallies with the written records. The manager is encouraged to record all informal complaints/concerns in the complaints log, including the action taken to resolve them. The outstanding recommendation made by the environmental health officer in June 2006 should be addressed. The home should continue working towards achieving 50 of the staff being qualified at NVQ level 2 in care. 2 OP16 3 4. OP19 OP28 Jasna Gora DS0000038443.V314644.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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.V314644.R01.S.doc Version 5.2 Page 29 - 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!