Inspection on 06/09/05 for Jasna Gora

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 28/11/06

Jasna Gora 07/02/06

Jasna Gora 03/02/05

Jasna Gora 23/09/04

Jasna Gora 04/03/04

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Hawkhills

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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 HD2 2JQ Lead Inspector Tracey South Irene Ward Announced 6 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Jasna Gora Address 52 Fixby Road Fixby Huddersfield HD2 2JQ 01484 451850 01484 451850 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Society of Christ (Great Britain) Mrs Anna Szczesna Care home - personal care only 12 Category(ies) of 12 x Older people (over 65 years) registration, with number of places Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 3 February 2005 Brief Description of the Service: Jasna Gora is a well maintained home offering care and accommodation for up to twelve 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. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 4 hours by 2 inspectors. One of the inspectors speaks Polish and was able to communicate with the residents and staff in their first language. There were 12 residents living at the home on the day of the inspection. Two residents, the manager and three members of staff were spoken to and their comments have been used as part of this report. A tour of the home was undertaken. Care records were examined during this inspection. What the service does well: Eight comment cards were received from relatives and the following comments were made. “This home should be a role model for others”. “The staff are wonderful with residents”. “Most wonderful home for my mother”. “I am very happy with the care and commitment of Jasna Gora staff”. “It is very clean and good food”. “Excellent”. “We are very, very grateful to everyone at Jasna Gora for all that they have done for our Dad and our family”. Nine comment cards were completed by residents, all of which indicated that they liked living at the home and felt well cared for. One resident said, “its good living here, staff are very good, the food is very good. They look after us all very well. Anna, the manager, is very good”. The home benefits from having its own chapel and a service is held each day at 8.30am. Staff explained that at least 5 residents attend the daily service. 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 meals are in the Polish culinary tradition. Residents and visitors to the home are treated with respect and there is a real emphasis on creating a homely atmosphere. Staff demonstrate a very caring attitude towards residents and provide care to them in a discreet and sensitive manner. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 6 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. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 Prospective residents are fully assessed prior to them being admitted to the home. EVIDENCE: Community care assessments, completed by a social worker, are forwarded to the home prior to the prospective resident moving into the home. This enables the manager and staff to make a decision as to whether the home will be able to meet the needs of the prospective resident. There was evidence that information provided in the community care assessment is used to form the basis of the initial care plan. It is clear from the comments received from relatives and friends and from speaking to residents themselves that people’s needs are being met. The Polish language, culture and traditions are observed and evidence of this was seen throughout this inspection. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 Care plans are detailed and give staff the information they require to meet residents’ needs. Daily reports do not provide sufficient detail to evidence that residents’ needs are being met. Residents have access to other health care services in accordance with their needs. EVIDENCE: The care plans in place provide detailed information about the needs of the resident. The needs of the residents are broken down into sections, such as, personal care, medication and mobility. Each section details the level of support required. Unfortunately, as detailed as the care plans are, the daily records do not provide enough information to demonstrate that the needs of the resident are being met. Reports were found to be repetitive. Daily reports should be written in such a way to demonstrate that care is provided in accordance with the care plan. The report should include details of the health, welfare and social care needs of that person. An “isolation” consent form was observed in place and the manager explained the reasons why this had been implemented. Whilst it is understood that some Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 10 residents may be disruptive and cause distress to other residents, it is not seen as appropriate or acceptable to implement strategies such as isolation. It was explained to the Manager that if a resident is displaying challenging behaviour, which is having an adverse affect on other residents, this must be reflected in the care plan. The care plan should detail the specific issues and the appropriate strategies to be used. Advice from other agencies such as the Mental Health Team should also be sought. The manager must also consider, when faced with problems such as this, whether the home is able to meet the needs of that particular resident. Care plans are reviewed every month by the Manager. All residents are registered with a GP and records of visits are maintained. Residents also receive support from other health care professionals such as the district nurses, opticians, chiropodist and speech and language therapist. A number of health care assessments were seen in place. These include, movement and handling assessments, personal risk assessments and Waterlow assessments (used to identify those people who may be at risk of developing pressure sores). All assessments are reviewed on a monthly basis. The people who live at Jasna Gora are treated with the greatest of respect and consideration at all times. Staff attended to the personal care needs of residents in a discreet and sensitive manner. Staff were observed using the residents’ preferred term of address. Evidence of this was also seen in writing. Screening is provided in both of the two double bedrooms. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 The Polish language, culture and traditions are observed. Relatives and friends are made to feel welcome when they visit the home. Residents are able to bring personal possessions with them on admission. The meals at the home are good. EVIDENCE: Residents gave positive feedback about their life at Jasna Gora. Residents enjoy watching television or listening to the radio. Some residents were seen reading the newspaper. There is a chapel within the home where residents are able to attend the daily service. Residents are also able to attend Mass each Sunday. Residents spoken to said they enjoy sitting in the garden when the weather is warm. Three residents were seen sitting outside the front entrance of the home during this inspection. The majority of residents sit in the lounge area. It was noted as being very quiet, a number of residents were asleep. One resident said “that’s how we like it”. Another resident said she wasn’t interested in going out anywhere as she had everything she wanted at the home. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 12 Visitors are made welcome. Positive feedback was received from relatives and friends of residents. Personal possessions were observed in place in those bedrooms seen. The residents spoken to said they enjoyed the food and the inspectors were invited to join the staff for lunch. The meal on offer was vegetable soup, potatoes, vegetables, meatloaf and gravy, followed by fruit salad. There is a four weekly menu in operation. Ukranian bread, Polish seasoning and meats were observed in place. Specialist diets are provided for. Soft diets are provided to those residents who experience difficulties with swallowing. Staff provide support to those residents who need assistance with feeding. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed during this inspection. EVIDENCE: Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,24,26 The home is clean and tidy and provides a comfortable environment for the residents. EVIDENCE: The home is situated in a quiet position off the main road. The grounds to the home are attractive and well maintained. Residents spoke of how they enjoyed sitting out in the garden when the weather is warm. The fire safety work mentioned in the previous inspection report has been completed. There are 8 single rooms and 2 double rooms. The majority of bedrooms were seen during a tour of the home. All bedrooms contained personal possessions belonging to residents. The rooms were clean and tidy. Screening is provided for those people who share a bedroom. One resident spoke of how she was quite happy about sharing her room with another resident. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 15 The home is clean, hygienic and free from unpleasant odours. The laundry is located on the ground floor. There is one industrial washer and one dryer in place. Recommendations have been made in the past to install a washing machine with a built in sluice programme. This has not been addressed. However, it was noted that the washing machine does have a pre-wash programme and a 95 degrees centigrade programme. The staff on duty were able to demonstrate a good understanding of infection control policies. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed during this inspection. EVIDENCE: Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The home has good health and safety procedures in place. EVIDENCE: The manager has a good understanding of health and safety issues. Movement and handling plans are in place for each resident. The plan provides details of the equipment to be used and the safe techniques to be used by the staff. The fire activation points are checked every week and the staff last received fire training on 18th March 2005. The most recent fire drill to take place was on 18th August 2005. The environmental health officer visited the home on 13th January 2005, the three recommendations made have been dealt with. The kitchen was found to be clean and well maintained. Food hygiene procedures are followed. Menus are written in both Polish and English. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 18 The passenger lift and hoists were being serviced on the day of the inspection. It was noted that the electrical wiring certificate had expired. The manager was confident that this had been renewed although there was no evidence of a new certificate. Once located, a copy of the certificate should be sent to the CSCI. All accidents are reported and recorded in accordance with the requirements of the Data Protection Act. The manager was not aware that the Commission must be notified of any event which adversely affects the well-being or safety of any resident. A copy of the pro-forma used to notify the Commission was left at the home. One of the toilets on the first floor did not have liquid soap or paper hand towels available. The manager must address this. It was noted that in the bathroom on the first floor, cleaning products had been left out on the windowsill. All cleaning products must be stored correctly to avoid unnecessary risks to residents. Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x 1 Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The mental health needs of residents must be highlighted within the care plan. Details of the strategies to be used when dealing with challenging behaviour must also be recorded. Daily reports must include sufficient detail to demonstrate that the needs of the resident have been met. The Commission must be notified in writing of (a) the death of any service user (b) the outbreak of an infectious disease (c) any serious injury (d) serious illness of a resident at the care home (e) any event in the care home which adversely affects the well-being or safety of any resident (f) any theft, burglary or accident in the care home. Liquid soap and paper hand towels must be made available in the first floor toilet. Cleaning products must be stored appropriately in accordance with COSHH regulations. 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Timescale for action Immediate 6th September 2005 and thereafter 2. OP38 37 Immediate 6 September 2005 and thereafter 3. OP38 16 4. OP38 13 16th September 2005 and thereafter Immediate 6th September 2005 and thereafter Page 21 Jasna Gora Version 1.40 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 22 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Jasna Gora 20050906 Jasna Gora IR OP J51 v238096 s38443.doc Version 1.40 Page 23 - 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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