CARE HOMES FOR OLDER PEOPLE
Jasna Gora 52 Fixby Road Fixby Huddersfield West Yorkshire HD2 2JQ Lead Inspector
Tracey South Unannounced Inspection 7th February 2006 09:45 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.V254515.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Jasna Gora Address 52 Fixby Road Fixby Huddersfield West Yorkshire HD2 2JQ 01484 451850 01484 451850 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) Miss 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.V254515.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th September 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 DS0000038443.V254515.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This 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. One resident was staying at the home for a short break. Several residents, 3 relatives, a visiting GP were spoken to and their comments have been used as part of this report. Documentation such as medication records, the complaints procedure, training data and staffing records were examined. What the service does well: What has improved since the last inspection?
Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 6 All the requirements made in the last inspection report have been addressed. 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 DS0000038443.V254515.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 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 the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 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 the following standard(s): 9 Resident’s medication is well managed. EVIDENCE: 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. It was not possible to reconcile all supplies of medication, mainly Paracetamol given on a PRN basis, that is, when required, as stocks from the previous month had not been brought forward. The manager was advised to introduce a brought forward system to ensure all medication can be easily reconciled with the records kept. Oxygen cylinders that are not in use are currently being kept in the office. The manager explained that this was due to a lack of storage space. The supplying of oxygen has recently changed and since 1st February 2006 oxygen is no
Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 10 longer being supplied through the local pharmacy, it is now being supplied direct from designated regional contractors. The manager was advised to contact the home’s oxygen supplier to seek their advice as to the safe storage of cylinders, when not in use, as the current arrangements are not adequate. Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 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 the following standard(s): None of the above standards were assessed on this occasion. EVIDENCE: Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has an effective complaints procedure in place. None of the staff have received adult protection training. EVIDENCE: The complaints procedure is written in both Polish and English and is displayed in the front entrance of the home. The home has not received any complaints since the last inspection in September 2005. There is a comments log available, which is located in the entrance of the home. The manager explained that although she deals with informal complaints and concerns raised by residents she does not record them in writing. The inspectors explained that it is good practice to document such complaints and concerns as well as outlining any action taken to resolve them. By doing this, the home is demonstrating that they listen to residents/relatives concerns and act accordingly. The home has an adult protection policy in place although it does not truly reflect how an incident of abuse would be dealt with. The policy is out of date and needs amending. A poster and leaflets on “how to report abuse of vulnerable adults” are displayed in the entrance of the home but the manager did not have a copy of the policy and associated guidelines. The manager was advised to obtain a copy of the Adult Protection Policy produced by Kirklees Metropolitan Council. Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 13 None of the staff at Jasna Gora have received formal training regarding adult protection issues. Without staff being trained in these procedures residents may be placed at risk. Every effort must be made to ensure all staff receive the appropriate training they need within the next 4 months. Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 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 the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29, 30 There are enough staff on duty to meet the needs of residents. Any new staff are thoroughly checked to ensure they are suitable to work with older people. Staff are trained and competent to do their jobs. EVIDENCE: There are 3 care assistants on duty throughout the day and one care assistant on wakeful night duty. In addition to this there is always one care assistant on call in the building at night. There were good levels of staff supervision observed and there was always a member of staff in the vicinity of the lounge. The manager, Anna Szczesna, works up to 37 hours per week between Monday and Friday. The care staff team are supported by cooks and domestic staff. All the staff at Jasna Gora speak Polish as their first language and are able to communicate well with the residents. The staff personnel files were well organised and all contained the necessary documentation demonstrating that thorough recruitment procedures had been followed. Training certificates were seen in place in respect of the 3 files examined. The manager explained that the staff have undertaken a number of training courses throughout the last 12 months. These include, manual handling,
Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 16 health and safety, basic food hygiene, first aid at work, medication and risk assessments. Eight of the staff are now registered to complete NVQ level 2, 2 of which have nearly completed their award. The manager is currently undergoing her Internal Verifiers’ award and a further 2 staff are working towards their Assessors’ award. Having the Manager and staff within the organisation being qualified as assessors has helped the care staff overcome communication problems such as the NVQ documentation being written in English. Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 The home is run in the best interests of the residents. Better systems for the safekeeping of resident’s monies must be applied. EVIDENCE: The manager explained how recent quality questionnaires have been given to residents to complete. The residents are supported to complete the questionnaires by either staff or relatives. Once the questionnaires have been collated the manager will produce a report outlining the findings. Previous questionnaires lead to further activities being provided and less use of garlic in the meals. It is clear from speaking to relatives and other professionals who visit the home that the residents at Jasna Gora are very well cared for. Two visitors spoken to during this inspection said they were impressed by the home, in particular its cleanliness and that the staff are welcoming and caring towards
Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 18 the residents. They went on to say that if they had to go into a home they would choose Jasna Gora. A visiting GP said “the home is very good and the staff are very conscientious”. The GP felt that the home meets the needs of residents it provides for, that is, people from Poland. 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 which must be sent to the Commission for Social Care Inspection. Small amounts of monies are held on behalf of residents. Individual accounts are stored securely and records of transactions are maintained. Receipts are kept in respect of any money spent. The CSCI were concerned to learn that if a resident is low in funds, money is borrowed from other residents without their consent. The manager was advised to cease this practice immediately. The manager periodically writes to relatives requesting monies for the resident in accordance with the individual’s spending requirements. The manager must ensure that the money requested from relatives is adequate, to avoid residents being without any funds and also to avoid the need to borrow money from others. Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 X X X X X X X X 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 X X 1 X 1 X X X Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 20 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. 1 Standard OP18 Regulation 13(6) Requirement Timescale for action 30/03/06 2 3 OP18 OP33 13(6) 26 4 OP35 16(2)(l) The home’s adult protection policy must be revised to ensure it meets with Department of Health guidance. All staff must receive adult 30/06/06 protection training with the next four months. A representative from the 30/03/06 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. The practice of borrowing 07/02/06 resident’s funds for other residents must cease immediately. 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 A brought forward system should be introduced to ensure
DS0000038443.V254515.R01.S.doc Version 5.1 Page 21 Jasna Gora 2 3 4 OP9 OP16 OP28 that all medication given “when required” can easily be reconciled with the medication records in place. The contractor responsible for supplying oxygen should be contacted to discuss the safe storage of the cylinders when not in use. The manager is encouraged to record all informal complaints/concerns in the complaints log, including the action taken to resolve them. The home should continue working towards achieving 50 of the staff being qualified at NVQ level 2 in care. Jasna Gora DS0000038443.V254515.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Brighouse Area Office 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
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