Inspection on 14/09/05 for Polonia

This inspection was carried out on 14th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Polonia 07/12/06

Polonia 03/01/06

Polonia 10/02/05

Polonia 17/08/04

Polonia 27/02/04

Polonia 29/08/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Polonia 17 Demesne Road Whalley Range Manchester M16 8HG Lead Inspector John Oliver Unannounced 14 September 2005 th 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. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Polonia Address 17 Demesne Road Whalley Range Manchester M16 8HG 0161 232 0719 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) Dr Andrzej Rozycki Dr Andrzej Rozycki Care home only (PC) 9 Category(ies) of Old age, not falling within any other category registration, with number (OP) (9) of places Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10 February 2005 Brief Description of the Service: Polonia is a residential care home registered for 9 places providing personal care. The home specialises in providing residential care to elderly people who are Polish, Ukrainian, and Russian. Other Slovian cultures could be catered for. Polonia is a semi-detached, three storey brick built house on a corner plot, with gardens to the front and one side. It is in the Whalley Range area of Manchester, which is a multicultural residential area within easy reach of the City Centre. Bedroom accommodation is provided on the ground and first floors. There are 7 single and 1 double room. None have en-suite facilities. There is a lounge on the ground floor and the dining room is located in the basement. Access to the basement and first floor is via a passenger lift. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 14th September 2005 over a four and a half hour period. This inspection involved spending time talking with the deputy manager and staff of the home. Time was also spent talking with a number of residents who wanted to say how they found living in the home. Some time was spent looking at files, records and the home’s policies and procedures. Time was also spent looking around the inside of the home as well as having a walk around the outside of the building. At the last inspection, which was done in February 2005, a number of improvements were identified that needed to take place. Many of these were still outstanding at the time of this inspection and have been included again in this report. Not all standards were checked at this inspection and it is strongly advised that this report should be read together with the last inspection report and any future inspection reports to get a full picture of how the service is meeting the needs of the residents living there. What the service does well: The management and staff team of the home have worked hard to provide and maintain residents with a comfortable and safe place to live. Watching staff at work gave a good indication of their commitment to providing residents with a pleasant home in which to live. The Polish culture and traditions are part of the everyday lifestyle for people living in the home and residents are encouraged to take part in making decisions about how they would like to spend their time. Meal times are seen as very important to the people living in the home and one resident spoken to said that “meals are really good” and, “you can choose what you want”. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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 Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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) 1,3 and 6 Although information about the home was available this needed further work. People’s individual needs were assessed prior to admission. EVIDENCE: Information available for potential residents that describes the service on offer in Polonia was included in the Service User Guide and Statement of Purpose. However, not all information had been translated into the Polish language which could make it difficult for those people whose first language is Polish. However, it is acknowledged that the timescale given at the last inspection for this work to be completed by had not expired at the time of this inspection. The files of three people admitted into the home during the last six months were examined. All had an assessment that had been completed by the deputy manager. Not all assessments had been fully completed which could result in relevant and important information being missed off an individual’s care plan. Polonia did not offer intermediate care and this was confirmed by the deputy manager. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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 and 9 Information with regards to residents identified care needs was available to show how the health and social care needs were being met. However, this did not always indicate the best ways of meeting those needs. Reviews of care plans and risk assessments had not been consistently carried out. EVIDENCE: Care plans and risk assessments had been completed for each resident living in the home. Although there had been some improvement in the information contained in both documents, there were still areas of inconsistency. Not all plans indicated how support should be given/offered by staff. This could prevent residents receiving the care they need in the most appropriate way. Evidence was available to indicate that some care plans and risk assessments had been reviewed on a monthly basis but not all. It is necessary that all care plans and risk assessments are reviewed regularly in order to maintain up to date information on how individual care support should be delivered. Medication was appropriately administered and information was readily available to support any resident who may be responsible for their own Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 10 medication. A requirement from the last inspection was that all rooms must have a lockable space. This requirement had now been met. Files contained relevant information relating to support given to residents living in the home by other visiting health care professionals. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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 and 14 Residents have choice and support to meet their expectations and preferences regarding their daily lifestyle. EVIDENCE: On the day of the inspection the routine of the home was very relaxed and informal. Discussion with the deputy manager confirmed that residents could spend time socialising in communal areas or in the privacy of their own rooms. One particular room seen during the inspection gave clear indications that the person who occupied the room had been given support to participate in activities of their choice and, in the privacy of their own room. Discussion with the deputy manager confirmed that, culturally, most residents preferred to chat rather than participate in ‘formal’ activities. Links continued to be maintained with the local community. A number of people living in the home attended a local club of the Polish Ex-Combanent Association. Occasionally, these meetings were held in Polonia at the request of people living in the home. Information was displayed around the home regarding the use of advocacy services and also details of a Polish speaking solicitor. People living in Polonia Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 12 were encouraged to bring in personal possessions with them on admission to the home and this was noted during the tour of the premises. Although there was evidence that visitors were welcome at the home and residents confirmed that they did receive visitors, none had signed the visitors book. This must be done to ensure the health and safety of those people living in and visiting the home. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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) 18 The home has relevant policies, procedures and systems in place to enable concerns to be raised and protect residents from neglect and/or abuse. However, staff would benefit from having professional training relating to the protection of vulnerable adults. EVIDENCE: The home had adopted the Manchester Multi-Agency Adult Protection Procedures and its own Adult Protection Policy was clear and related directly to ‘No Secrets’ guidance. However, other than the deputy manager taking staff through the procedures relating to adult protection no other relevant training had taken place. It is recommended that specific adult protection training should form part of the core training to all staff. The ‘Whistle Blowing’ policy had been seen during the last inspection and evidence showed that this policy was made available to all staff as part of their induction process/training. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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) 19,21,25 & 26 The general environment of the home was clean, tidy and comfortable with systems in place to protect the safety of residents. EVIDENCE: The registered manager of the home had developed and produced a programme of routine maintenance and renewal of the fabric and decoration of the premises. Since the last inspection a number of bedrooms had been repainted. During a tour of the premises it was noted that the carpet on the hallway and downstairs corridors had become worn and uneven. This must be replaced to prevent a tripping hazard to people living and working in the home. The doorframe to room 8 was loose and coming away from the wall. This must be re-fixed to prevent any risk to the resident whose room it is. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 15 Those bedrooms viewed during the inspection were clean, comfortable and personalised to varying degrees reflecting the character of the resident. Bathroom and toilets were sufficient in numbers to meet the resident’s needs and all doors had appropriate privacy locks fitted. Laundry facilities were appropriate and fit for purpose and all care staff had been enrolled to attend a course on the ‘control of infection and contamination’. During the inspection it was noted that there appeared to be an ‘air lock’ in one of the water pipes running near to the dining room. This was making a loud ‘banging’ noise when water was running. This must be investigated and appropriate action taken. Externally, the property was well maintained. Regular painting of the exterior woodwork was included in the rolling programme of maintenance. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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) 27,28 and 29 The home’s recruitment and training policies and procedures were in place and provided enough details to support the employment of sufficient well trained staff. However, these policies and procedures had not been adhered to in all cases. EVIDENCE: The deputy manager confirmed that the staffing levels at the home met the current needs of all residents’ living there. Discussion with two residents confirmed this to be the case. In addition to day care hours, one member of staff was on waking night duty with a manager sleeping in on the premises each night. The files of two staff employed in the home were checked. Not all required documentation was available e.g. application form and two written references. Staff must not be employed in the home until all relevant documentation has been completed/received and fully checked. Failure to do this can place people living in the home at risk. At the time of the inspection no staff had achieved National Vocational Qualifications (NVQ) at level 2 and none were working towards NVQ level 2. Staff must be given the opportunity of obtaining this qualification to further enhance their skills in the delivering of a good standard of care within the home. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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) 35,36,37 and 38 Some practices relating to the record keeping, policies and procedures of the home did not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: From information provided by the deputy manager, no resident managed their finances independently although they were encouraged to manage their own financial affairs for as long as they were able to do so. In most cases, relatives acted as appointee for those people who required support to manage their finances. For those people supported by the home to manage their personal allowance it was seen that written records of all transactions were kept, and, receipts had been obtained for all purchases made. Balances of cash were checked and found to be correct however; money was accumulating in large amounts and should not be kept on the premises, as this is a risk. Alternative methods of Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 18 managing this cash (individual bank accounts etc) were discussed fully with the deputy manager who agreed to deal with this matter. Since the last inspection the registered and deputy manager have worked closely in order to improve their methods of managing the home and the standards of practice carried out to ensure that the service provides appropriate care and will safeguard the welfare of the residents. However, further improvements were required and have been identified in this report. Discussion with a number of staff during the inspection confirmed that they receive regular one to one supervision and, also, regular ‘team’ meetings. This gave individual staff time to discuss their work role and identify any training needs that they may have. Records such as staff files were not all up to date. The file of the last person to be employed by the home did not contain information such as: an application form and two appropriate written references (although a Criminal Record Bureau check had been obtained). Lack of such important information can place residents at risk. This has been addressed under Standard 29. Relevant certificates were on file to show that appropriate servicing of all equipment used by residents in the home had been carried out. Discussion with the deputy manager indicated that training for all staff in Basic Food Hygiene, Moving and Handling and Basic First Aid were proving difficult to arrange because of language difficulties. However, it is commendable that the staff in the home are paying privately for lessons in the English language to enable them to have a better understanding of issues such as training and service delivery. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 x COMPLAINTS AND PROTECTION 2 x 3 x x x 3 3 STAFFING Standard No Score 27 3 28 1 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x 3 3 2 2 Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.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 1 Regulation 5 Requirement The registered provider shall produce a service user guide containing those details described in Regulation 5. A copy of this guide shall be sent to the Commission (Previous timescale 30/04/05 not met). The Service User Guide must be translated into the Polish language. Assessments of residents needs must cover all areas identified in 3.3 of the Naitonal Minimum Standards. (a) Care plans must set out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the residents are met. This must be done with the full involvement of the resident and/or their representative. (b) Information must be recorded and the residents signature obtained (if appropriate) (Previous timescale 30/04/05 not met). Timescale for action 28th October 2005 2. 3. 1 3 5 14 30/09/05 28th October 2005 on going 28th October 2005 on going 4. 7 15 Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 21 5. 7 15 6. 13 17 Schedule 4 13 13 23 18 19 7. 8. 9. 10. 11. 19 19 19 28 29 12. 38 13 28th October 2005 on going All visitors to the home must 28th sign in and out of the October premises. 2005 on going The carpet in the hallway and 30th downstairs corridors must be December replaced. 2005 The doorframe around the 28th bedroom door of room 8 must be October re-fixed to the wall. 2005 A suitably qualified person must 28th check the water system and October clear the air lock. 2005 Staff must given opportunities to 30th attain National Vocational December Qualification level 2. 2005 All relevant information required 28th to be obtained before a person October commences their employment in 2005 on the home must be obtained and going be kept on file. All care staff must complete 30th accredited Moving and Handling December training and Basic First Aid 2005 training. All staff responsible for handling food must complete Basic Food Hygiene training (Previous timescale 30/06/05 not met). Care plans must be reviewed at least once a month. 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 18 Good Practice Recommendations It is recommended that all staff receive appropriate training in adult protection procedures. Polonia F55 F05 s21576 Polonia V248126 D090905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 9th Floor, Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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