Inspection on 03/01/06 for Polonia

This inspection was carried out on 3rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Polonia 07/12/06

Polonia 14/09/05

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 Inspection 3rd January 2006 10:20 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 Polonia DS0000021576.V275676.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. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Polonia Address 17 Demesne Road Whalley Range Manchester M16 8HG 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) 0161 232 0719 Dr Andrzej Rozycki Dr Andrzej Rozycki Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 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 DS0000021576.V275676.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on Tuesday 3 January 2005 starting at 10.20am. The inspection involved spending time talking with the deputy manager and one particular resident living in the home. This resident wanted to say how they found living in the home. Some time was spent looking at files, records and some policies and procedures. A tour of some parts of the home was also undertaken. An inspection was also carried out in September 2005 and a number of improvements were identified that needed to take place. Some of these had been completed when they were checked and others were still outstanding. Where these had not been done they have been reiterated 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 to get a full picture of how the service is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? Since the last inspection staff have received training in Food Safety and The Control of Infection and Contamination. A tutor from North Trafford College carried out this training in-house. At the time of the inspection the deputy manager was also in the process of registering staff for Moving and Handling training, First Aid training and training in Managing and Safe Handling of Medicines. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 6 Due to the difficulties in trying to find a suitable resource to provide National Vocational Qualification training using the Polish Language it is commendable that the staff have paid individually to study English Language to support them in achieving this qualification. 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 DS0000021576.V275676.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 Polonia DS0000021576.V275676.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): 1, 3 and 6 Information about the home was available to prospective residents. Peoples’ 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. It is commendable that, since the last inspection, the information had also been translated into the Polish language, which would make it easier for those people whose first language is Polish. No new residents had been admitted to the home since the last inspection, which was carried out in September 2005. A requirement from that inspection was that when an assessment of a potential resident was carried out, that assessment must cover all areas identified in 3.3 of the National Minimum Standards (NMS). The deputy manager at that time said she would review and update the assessment document used by the home to ensure that it met the NMS. This still had not been done and the requirement has been reiterated in this report. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 9 Polonia did not offer intermediate care and this was confirmed by the deputy manager. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 10 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): 7, 10 and 11 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 were inconsistent. EVIDENCE: Care plans and risk assessments had been completed for each resident living in the home. At the last inspection improvements had been noted in information contained in both these documents. However, there had been little improvement since and inconsistencies were still present in how information was being recorded by staff. Not all plans indicated how support should be given/offered by staff. Statements such as “requires full assistance” needs to be further clarified to indicate exactly what that “full assistance” means and involves. If this is not done it could prevent residents receiving the care they need in the most appropriate way. Evidence was available on some files to show that care plans and risk assessments had been reviewed on a monthly basis but not on all. It is necessary that all care plans and risk assessments are reviewed regularly in Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 11 order to maintain up to date information on how individual care support should be delivered. At the time of this inspection one resident was very poorly and receiving total bed care. Staff were seen dealing with this persons needs in a dignified and respectful way and evidence was seen of intervention with other healthcare professionals e.g. district nurse and general practitioner. Pain relief was being fully monitored to ensure the person remained as comfortable as possible. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 12 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): 13 and 15 Residents have choice and support to meet their expectations and preferences regarding their daily lifestyle. Contact with family/friends/representative and the local community is maintained. EVIDENCE: On the day of the inspection the routine of the home was very relaxed, informal and, unhurried. A number of residents had finished breakfast and were watching daytime television in the lounge. A requirement from the last inspection that visitors to the home were asked to sign the visitors book in compliance with the health and safety procedures in the home had been met. The signatures contained in the visitor’s book clearly demonstrated that residents received visitors on a regular basis. Meal times were seen as an important part of the day and were planned with the individual residents in mind. Most chose to have their meals either in the lounge area or in their own rooms. Menus are planned over a two weekly cycle but can be changed daily to meet the choices of individuals. On the day of the inspection the menu for lunch was: chicken noodle soup, chicken, potatoes and fresh vegetables followed by cherry pie and custard. One particular resident said “Food is the best thing of the day”, “I look forward to it”. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 13 The kitchen area was found to be clean, tidy and bright. All staff had recently completed training in Food Safety – Principles and Practices. However, on the day of the inspection it was seen that people were wandering in and out of the kitchen whilst food preparation was taking place. This could place residents at risk e.g. contamination of food. A requirement has been made under standard 38. The temperatures of both ‘fridge and freezer were recorded on a daily basis. However, discussion with the deputy manager confirmed that when cooking meat/chicken the cook did not ‘probe’ the meat to ensure correct temperatures were maintained. This could place residents at risk. A requirement has been made under standard 38. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 14 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 The home has relevant policies, procedures and systems in place to enable concerns to be raised. EVIDENCE: It was confirmed by the deputy manager that the home had received no complaints since the last inspection. The Commission for Social Care Inspection had received no complaints at the time of this inspection. The home had a complaints policy and procedure in place but this required updating to inform people that they can contact the Commission for Social Care Inspection at any stage of their complaint and not just if they are unhappy with the results of any investigation the home may carry out. The policy and procedure was also available in the Polish language. A recommendation made at the last inspection that staff receives appropriate training in adult protection procedures had not been addressed. This recommendation has been reiterated again in this report. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 15 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): 19 The general environment of the home was clean, tidy and comfortable. Some work was required to maintain the environment in a safe condition for residents. EVIDENCE: On the day of the inspection the home was clean and tidy with no unpleasant odours detectable. A requirement from the last inspection was that the carpet on the hallway and downstairs corridors be replaced as they had become worn and uneven and presented a potential tripping hazard to people living and working in the home. At the time of this inspection this had still not been replaced and the requirement has been reiterated in this report. The carpet on the stairs leading from the basement up to the first floor has become worn in places and needs replacing to prevent a tripping hazard to staff. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 16 An audit of all carpets throughout the remaining corridors and stairs in the building must be carried out and be replaced wherever needed to prevent any hazards to the health and safety of residents and staff. The doorframe to room 8 is loose and coming away from the wall. A requirement was made at the last inspection for this to be repaired. This has been reiterated in this report. A number of bedroom doors were not fitting into their rebates effectively and as these doors are fire doors there is a risk to the safety of residents. A full audit of all doors must be carried out and adjustments made where necessary. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 17 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): 28, 29 and 30 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. EVIDENCE: 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. Discussion with the deputy manager indicated that the home was having difficulty in finding a suitable training resource that could provide this training to staff using the Polish language. However, it is commendable that the staff have funded themselves studying the English language via a private tutor. This they hope will give them a better opportunity of obtaining this qualification to further enhance their skills in the delivering of a good standard of care within the home. A recommendation regarding NVQ training has been made in this report. Although individual training and developments records/assessments were not held on staff files there was evidence that staff had recently attended different training events. All staff had successfully completed a “Food Safety – Principles and Practices” course using a tutor from North Trafford College. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 18 All staff had successfully completed “The Control of Infection and Contamination” course using a tutor from North Trafford College. The deputy manager confirmed that arrangements were being made for the provision of: Moving and Handling training, First Aid training and, Managing and Safe Handling of Medication for all staff. A requirement made at the last inspection for all relevant information to be obtained before a person commences their employment in the home had now been met. The deputy manager confirmed that she was now very clear about not employing any new staff until all such information had been obtained, checked and put on file. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 19 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, 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: The home has produced a questionnaire that is given to all new residents approximately 3 months after moving into Polonia. The questionnaire included questions relating to: * Admission * Catering and Food * Personal Care and Support * Daily Living Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 20 * Premises * Management However, no evidence was available to show what action (if any) has been taken to address any issues/ideas/concerns that may be identified through information provided via the questionnaires. In order to monitor if the home is being run in the best interests of the residents these questionnaires must be done at least annually and the information gathered from them used to further develop and improve the service offered by the home. Records held on both residents and staff were not all up to date nor accurate with the information contained within them. This included reviewing care plans and risk assessments of residents and training records being kept on staff files. Lack of such important information can place residents at risk. Relevant certificates were on file to show that appropriate servicing of all equipment used by residents in the home had been carried out. As stated previously, discussion with the deputy manager confirmed that training was being arranged for all staff in Moving and Handling, First Aid and the Managing and Safe Handling of Medicines. A requirement from the last inspection regarding training has been reiterated in this report. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X 2 2 Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 22 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 OP3 Regulation 14 Requirement Assessments of residents needs must cover all areas identified in 3.3 of the National Minimum Standards (Previous timescale 28/10/05 not met). (a) Timescale for action 24/02/06 2 OP7 15 (b) Care plans must set out 31/03/06 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. Information must be recorded and the residents’ signature obtained (if appropriate) (Previous timescale 28/10/05 not met). 31/03/06 3 OP7 15 Care plans must be reviewed at least once a month. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 23 4 OP16 22 5 OP19 13 6 7 OP19 OP19 13 13 8. OP19 13 9. OP19 13 10 OP30 12 & 18 It must be ensured that information relating to complaints is updated to state that residents can refer a complaint to the Commission for Social Care Inspection at any stage, should the complainant wish to do so. The carpet in the hallway and downstairs corridors must be replaced (Previous timescale 30/12/05 not met) The carpet on the stairs leading from the basement up to the first floor must be replaced. An audit of the carpet on the remaining corridors and stairs must be undertaken and replacement carried out if/where identified as needed. The doorframe around the bedroom door of room 8 must be re-fixed to the wall (Previous timescale 28/10/05 not met). An audit of all fire doors, including bedroom doors must be undertaken and adjustments made to those doors that do not fit into their rebates effectively. A training and development programme meeting the full requirements of NMS 30 must be developed. 24/02/06 31/03/06 31/03/06 31/03/06 24/02/06 24/02/06 31/03/06 11. OP33 24 Effective quality assurance and 31/03/06 quality monitoring systems must be developed and put into place to measure the success in meeting the aims, objectives and statement of purpose of Polonia. Records required by regulations for the protection of residents and for the effective and efficient running of the business must be maintained, up to date and accurate. DS0000021576.V275676.R01.S.doc 12. OP37 17 31/03/06 Polonia Version 5.1 Page 24 13 OP38 13 14 OP38 13 & 16 15 OP38 13 & 16 16 OP38 13 All care staff must complete accredited Moving and Handling training and First Aid training (Previous timescale 30/12/05 not met). Food preparation must include using a ‘probe’ to check and record temperatures of meats being cooked and at the point of serving. No unauthorised person must enter the kitchen during the preparation of food. All staff authorised to be in the kitchen must wear appropriate protective clothing. Hot water temperatures must be regularly monitored with a record kept to ensure the safety of residents. 31/03/06 24/02/06 24/02/06 24/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP18 OP28 Good Practice Recommendations It is recommended that all staff receive appropriate training in adult protection procedures. It is recommended that ways of staff obtaining National Vocational Qualification training is continued to be explored. Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection CSCI, Local office 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. Extracts may not be used or reproduced without the express permission of CSCI Polonia DS0000021576.V275676.R01.S.doc Version 5.1 Page 26 - 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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