Inspection on 07/12/06 for Polonia

This inspection was carried out on 7th December 2006.

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

The inspector 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 03/01/06

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 7 December 2006 10:00 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.V299018.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 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.V299018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 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 bedroom. 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. The range of accommodation fees charged was between: £358:09 and £373:54 Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Polonia included an unannounced site visit as part of the inspection process. The inspection was carried out over a period of six hours during which, time was spent talking to the deputy manager and several residents. Documents including staff files, records and other relevant documentation were also examined. Information was also obtained from documentation held on file at the offices of the Commission for Social Care Inspection. Other information was taken from the pre-inspection questionnaire completed by the manager prior to the inspection visit taking place. A tour of the building was conducted to make sure the home was safe and that the people receiving a service were provided with a homely and comfortable place in which to live. The inspection report from the visit carried out in January 2006 highlighted a number of areas that the home needed to work on and improve. The majority of these areas were found to have been addressed. Nationally, during a two-week period the Commission for Social Care Inspection required all key inspections of residential homes providing service to older people to look at certain National Minimum Standards (NMS 1,2,3 and 16). These standards relate to the theme of quality of the information given to prospective residents and the contract and terms of conditions provided. The theme also looked at the provision of assessments of residents’ needs before they came to live at the home and whether they had been provided with information about how to raise their concerns and make a complaint. To enable these NMS to be assessed, relevant files and documentation were seen and discussions held with the manager, staff, and where possible, residents. The outcome of the findings has been recorded in the main body of the report. What the service does well: The management and staff team of the home had continued to work hard to provide residents with a comfortable place to live. Watching the staff interacting with the residents gave a good indication that people living in the home felt comfortable with the staff team. Comments from some of the residents living in the home included: “First class place”. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 6 “Food – what can I say – very good – plenty”. “You have food you want”. “What you want you have”. “My family visit me”. “Everything is good”. “Staff look after me well”. The home continues to make sure that residents can still enjoy participating in things that are important to them as part of the Polish culture such as supporting people to maintain links with the Polish community. The home was well maintained and the management made sure those things such as health and safety, which included Fire Safety and good practice relating to food preparation and storage was strictly adhered to. What has improved since the last inspection? What they could do better: Care plans and risk assessments for all residents must be reviewed and updated (where required) on a regular basis. Where a resident needs support with their mobility or to move around the home, it is important that an appropriate risk assessment is developed in relation to Moving and Handling. This would help to maintain the safety of both residents and staff. Although the home did on occasions, provide residents with a questionnaire to ask how the home meets their individual needs, this should be done as part of an annual review of the service provided by Polonia. Questionnaires should be extended to other interested parties also i.e. relatives; staff, care managers etc and their views could then be used as contributions to an annual development plan for the home. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 7 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.V299018.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information was available to inform prospective residents about the home. People’s needs were assessed before admission into the home and arrangements were confirmed. EVIDENCE: The home had a Service User Guide (SUG) and this was written in both Polish and English. Some information, such as the guidance relating to complaints needed reviewing and updating to ensure that the information and details are correct. This has been addressed under the National Minimum Standard 16. Discussion with the deputy manager confirmed that all prospective residents and/or their representatives were given a copy of this guide prior to any admission into the home taking place. Those residents’ spoken to during the inspection could not remember whether they had received a copy or not. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 10 It is recommended that an updated copy of the Service User Guide be made readily available to those residents and/or their relatives who may wish to access it at any time. A number of resident files were examined as part of the inspection process. On those files seen, contract arrangements/increase in fees information and breakdown of finances were available. Those residents spoken to during the visit were unsure of how their finances were dealt with, although one resident did say, “my son deals with all finances”. Further discussion with the deputy manager about contract arrangements for individual residents confirmed that the majority of the residents were funded through purchasing authorities such as the Local Authority and Primary Care Trusts. Where this is the case, then the contract is between the resident and the authority and not with the home itself. The home is paid in full by the authority and not by the resident. One file examined demonstrated that this resident was paying privately for their care and a contract with the home was dated and signed. Files seen demonstrated that the funding authority had carried out preadmission assessments for the three residents whose files were examined. One clearly stated that the authority would not be funding the placement due to the individuals’ personal financial status. The home had also carried out a pre-admission assessment of each prospective resident. It is recommended that following this assessment, the home write to the individual to confirm that the home can/cannot meet their identified needs. Two of the three residents’ spoken to about their admission into the home could not remember the pre-admission process being carried out, the third said, “Yolanda (deputy manager) saw me in hospital”. Of those assessments seen that had been carried out by the home, two of the three needed dates and the signature of the person completing the assessment. Wherever possible, prospective residents and their family/representative were encouraged to view the home prior to making any decision about admission. The home did not provide an intermediate care service. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The on going health care needs of residents had been identified and were being met although further work was required to ensure consistency in the systems used. Medication policies and procedures were being adhered to. EVIDENCE: Care plans had been developed for all residents living in the home using the information gathered from care management assessments and the homes’ own pre-admission assessment documentation. Of those care plans examined; information was made available to support staff to meet the identified needs of the individual resident. Since the last inspection visit in January 2006, the deputy manager had reviewed the care planning format and had further developed this to make sure that individual needs were clearly identified and, how these needs could best be met. Evidence was available to demonstrate that risk assessments had been developed to help manage a number of things such as, the use of cot sides and risk of falls. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 12 However, no risk assessments were in place for those residents who may need support and assistance with their mobility or to move around the home. This could place residents at risk of inappropriate assistance being offered by staff in the home. Although there was some evidence to show that some care plans and risk assessments had been reviewed on a monthly basis this was not clear on all care plans. 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. Records seen also demonstrated that other health care professionals were involved in meeting the identified health needs of individual residents. Medication was appropriately administered and records were accurately maintained. Observing staff in the daily routines of the home demonstrated that they treated each resident in a dignified and respectful manner and residents spoken to offered the following comments: * * “Staff look after me well”. “Staff know I like to be in my own room and respect me for this”. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 13 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): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had choice and support to meet their expectations and preferences regarding their daily lifestyle. EVIDENCE: On the day of the inspection visit the routine in the home was very relaxed, informal and, unhurried. Most residents were sat relaxing in the lounge talking with each other and staff. Discussion with a number of the residents confirmed that, culturally, most residents preferred to chat rather than participate in ‘formal’ activities. However, access to Polish television, videos and reading materials was readily available to all residents. Links continued to be maintained with the local community, including the Polish church. Information was displayed around the home regarding the use of advocacy services and also details of a Polish speaking solicitor. People living in Polonia were encouraged to bring in personal possessions with them on admission to the home and this was noted during the tour of the premises. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 14 Discussion with residents, and evidence seen in the visitor’s book confirmed that visitors were welcomed to the home. Comments from residents included: “My family visits me”, “My friend comes now and again”, and, “My sister comes once a month”. 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 or their own rooms. Menus were planned over a two weekly cycle but could be changed daily to meet the choices of individuals. On the day of the inspection the menu for lunch was: chicken noodle soup, chicken in sauce, potatoes and fresh vegetables followed by various choices of desert. Comments from residents included: “Food – what can I say – very good – plenty”, “You have food you want”, “The food is really good” and, “What you want you have”. The kitchen area was found to be clean, tidy and bright. A requirement made at the last inspection that no unauthorised person must enter the kitchen during the preparation of food and that appropriate protective clothing must be worn, had been fully met. New kitchen units had been fitted, and a new ‘double range’ gas cooker had been installed. Evidence was available to confirm that all staff had completed Food Safety training. Arrangements had been made to celebrate the holiday season, with Christmas Eve being the most important day in the Polish culture. No meat was taken between midnight on 23 December and midnight on 24 December. Culturally appropriate meals, including 12 ‘special’ dishes were planned to be prepared during this period. Christmas presents will be given on Christmas Eve, with the home entertaining residents, their families and friends. A Polish folk group had been planned to entertain everyone with traditional folk songs and music. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 15 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 and 18 The outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The home has relevant policies, procedures and systems in place to enable concerns to be raised and to protect residents from neglect and/or abuse. EVIDENCE: It was confirmed by the deputy manager that the home had received no complaints since the last inspection visit. 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 was in need of updating to inform residents/relatives/advocates that they could contact the Commission 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. The home had adopted the Manchester Multi-Agency Adult Protection Procedures and its own Adult Protection Policy was clear and related directly to the local authority’s ‘No Secrets’ guidance. Discussion with the deputy manager confirmed that staff had received training in ‘Understanding Abuse’ and evidence of training certificates were seen. Further discussion with the deputy manager confirmed that she had a clear understanding of the procedure to adopt in the event of any allegation of abuse being made. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 16 Residents spoken to offered the following comments: “Worries – I go to staff”, “I go to Yolanda (deputy manager)”, and, “I would go to the Doctor (registered manager/provider) if I had any complaints or worries”. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and hygienic and issues relating to maintenance of the property were being addressed so residents felt comfortable in their surroundings. EVIDENCE: On the day of the inspection visit the home was clean and tidy with no unpleasant odours detectable. A number of requirements made in the last inspection report regarding the environment had been met. The registered manager had carried out a full audit of corridor and stair carpets and had replaced them with new carpets where needed. The lounge area had also been fitted with a new carpet and had been redecorated and Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 18 repainted, making the lounge much brighter. Discussion with the residents in this lounge confirmed that they were happy with these improvements. Whilst walking around the home it was easy to see that improvements had been made to the premises in order to add to the comfort and security of the residents. New UPVC double-glazing units had been installed throughout the whole house and these units included ‘restricted’ opening for added safety. However, a number of keys were still in place in the locks, which meant that the windows could be fully opened should the key be fully turned. Risk assessments must be carried out for each resident to ensure their safety regarding the use of these keys. For the added security of both residents and staff, new electronic gates had been fitted to the pathway leading to the front door and side entrance to the home that were accessed via an intercom system. Staff took pride in the cleanliness of the home and were well supported by the owner who did some additional cleaning to make sure the home remained fresh and clean at all times. An infection control policy was in place and the member of staff interviewed was able to described safe infection control practice. Disposable gloves, aprons and appropriate bacterial hand wash were made available to all staff. Also, since the last inspection visit, a machine had been rented that could dispose of soiled continence products effectively and hygienically. Thermostatically controlled valves had been fitted to all hot water outlets accessible to residents and these were checked on a weekly basis in order to minimise risk to those residents living in the home. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment and selection procedures were good and on going training was in place for staff to ensure that they are competent to carry out their job. However, improvements were needed to induction training. EVIDENCE: Examination of staffing rotas and discussion with the deputy manager confirmed that staffing levels at the home met the current needs of all residents’ living there. 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. When spoken to about staffing in the home residents offered the following comments: “Staff look after me well”, and, “(There is) always enough staff – they make sure I am OK”. No new staff had been employed since the last inspection visit but one staff file was randomly selected to be examined. The file was found to be appropriately maintained and included an enhanced Criminal Record Bureau check, 2 written references, a Home Office employment check and other relevant documentation. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 20 Evidence of training certificates were available and included: * * * * * * * Food Safety – Principles and Practice First Aid – Appointed Persons Moving and Handling Understanding Abuse H & S in the Workplace Understanding Dementia Infection Control 07/04/06 24/03/06 23/01/06 09/01/06 03/08/06 28/08/06 21/08/06 Two members of the senior staff team had completed National Vocational Qualification (NVQ) Level 3 training in May 2006 and four other members of the staff team were currently working towards gaining NVQ Level II awards. Discussion with the deputy manager indicated that new staff would complete an in-house induction that would involve shadowing an experienced member of the staff team. Induction training must be developed in line with the National Minimum Standards to ensure that all new staff has opportunity to gain a clear understanding of their individual job role. Talking with a member of staff offered the following comments: * * * “Training is very good”. “We have a good staff team”. “No one lets you down – all staff are reliable”. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 21 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): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the home was run in the best interest of residents there was some room for improvements to be made. EVIDENCE: Since the last inspection visit to the home in January 2006 the registered and deputy manager had 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 that will safeguard the welfare of the residents. Improvements had been made in the way information was gathered in staff files and in the way in which training for individual members of staff was being Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 22 developed and monitored. This would help to ensure that only appropriate staff with the right skills and knowledge would be employed in the home. Comments from staff about the management of the home included: * * * * * “The (registered) manager talks with me regularly, about the home, the residents, and, management issues”. “I feel supported”. “A lot of work has been carried out in the home in the last 6-12 months”. “They (management & staff) really care about people”. “I have no concerns at all”. Although no formal quality assurance system was in place, evidence was seen to show that the home had used questionnaires to gather the opinions of residents about the service that they received. The questionnaire included questions relating to: * * * * * * Admission into the home Catering and Food Personal Care and Support Daily Living Premises Management However, these questionnaires were used infrequently and from when last completed, did not demonstrate what action, if any, had 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 interest of the residents these questionnaires should be done at least annually and the information gathered from them used to further develop and improve the service offered by the home. 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, close Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 23 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 check and found to be correct. However, some balances were accumulating in large amounts and should not be kept on the premises, as this is a risk. Alternative ways of managing this cash (individual bank accounts, social services etc) were discussed with the deputy manager who said she would deal with this matter. Relevant certificates were on file to show that appropriate servicing of all equipment used by residents and staff in the home had been carried out. Information was available to demonstrate that the home had received a visit from the Greater Manchester Fire Service in August 2006 and at that time all relevant regulations were being complied with. A representative from Manchester City Council’s Environmental Health Department visited the home in June 2006. During this visit the kitchen and food store areas were fully inspected. The report completed at the time confirmed that a ‘High standard was being maintained’ and that no further visits would be planned. A random selection of certificates relating to the servicing and maintenance of equipment were examined and included: * * * Fire Alarm servicing: 09/06/06 Gas Safety check: Fire Equipment: 26/09/06 27/11/06 Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 13 (4) (b) (C) Requirement Risk assessments must be developed in relation to Moving and Handling for individual residents and must be included as part of their care plan. An audit of all windows must be completed and risk assessments carried out where required. Timescale for action 23/02/07 2. OP19 13 (4) (a) (b) (c) 23/02/07 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 OP1 OP3 Good Practice Recommendations It is recommended that the Service User Guide be reviewed and updated where required and a copy made available to all residents. It is recommended that following assessment, the home writes to the individual to confirm that the home can/cannot meet their individual needs. All assessments should contain the date of the assessment and the signature of the person carrying out the assessment. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 26 3. 4. 5. 6. OP33 OP35 OP19 OP30 It is recommended that the home further develop the system used to gather information about quality assurance. It is recommended that alternative arrangements be considered for ‘banking’ accumulated personal allowances. Careful consideration must be given if individual residents are to be provided with keys to open the new UPVC windows. All staff must receive appropriate induction training within 6 weeks of appointment to their posts. Polonia DS0000021576.V299018.R01.S.doc Version 5.2 Page 27 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.V299018.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!