Care Home: Jasna Gora

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What the care home does well People`s care needs are properly assessed and they are given the opportunity to stay at the home before they move in permanently. This helps them make an informed decision about whether Jasna Gora is the right place for them to live. People are given enough information about the home before they move in. The registered manager from the home visits them and they are offered the opportunity to visit Jasna Gora for a look around and to ask questions about the home.This enables them to make an informed decision as to whether the home is the right place for them to live. People living in the home said, "Very good manager". " It is very good living here". One comment made on a survey received from a Health Care Professional. When asked, what do you feel the care service does well? A GP commented, "Centred on the client. Very caring and compassionate. Always calm and dignified". When asked is there anything else you would like to tell us a GP said, "Jasna Gora provides excellent care. They looked after a lady in her terminal illness very well - very professional and an excellent standard of care - so that she was able to die with dignity in her own `home` rather than distressed in hospital where she couldn`t speak English". The information kept about people is good and is the right kind of information needed; this helps staff support people properly all of the time. Although this area can be improved. Food at the home is traditionally Polish. A good choice of food and drinks are available. This ensures that people receive a varied and nutritious diet and the sort of food that people from Eastern Europe are used to. One person spoken to said, "Food is like what you would cook at home" When staff come for a job at Jasna Gora all the right references and police checks are completed, this means that it is less likely that unsuitable staff are employed to work at the home. People request to live at Jasna Gora because they know their cultural and spiritual needs will be met. What has improved since the last inspection? Waterlow risk asessments are carried out for those people who have been identified as being at risk of developing a pressure sore. This makes sure that any pressure sores are managed well and improvements are made, so that people`s health does not deteriate. The two commodes that were rusty have been replaced with new commodes. The home continues to work towards achieving 50% of the staff being qualified at NVQ(National Vocational Qualification) Level 2 in Care. What the care home could do better: The registered provider must make sure that all staff working at the home have up to date safeguarding training. This will make sure that people living at Jasna Gora are protected from harm. The registered provider must consult with the fire authority in making sure that staff have the required fire training that is neccessary. This makes sure that people living at Jasna Gora are always safe. The registered manager should make sure that care plans are updated to reflect how staff at the home meet the personal care needs of people.This includes how staff actually support people to have a bath. This makes sure that staff meet people`s needs when assisting them with personal care such as bathing. The registered manager needs to look at ways the home can improve the activities that are available to people living at the home. This will improve the quality of life for people at Jasna Gora. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Jasna Gora 52 Fixby Road Fixby Huddersfield West Yorkshire HD2 2JQ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Irene Ward     Date: 2 1 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Jasna Gora 52 Fixby Road Fixby Huddersfield West Yorkshire HD2 2JQ 01484451850 01484469473 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Society of Christ (Great Britain) care home 12 Number of places (if applicable): Under 65 Over 65 12 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who can be accommodated is: 12 The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 12 Date of last inspection Brief description of the care home Jasna Gora is a well-maintained home offering care and accommodation for up to twelve, predominately Polish, older people. It is an attractive house set in large, accessible and well-maintained grounds and situated in a quiet position off the main road. There is a bus route nearby. There is a lounge, a dining room, eight single bedrooms and two double bedrooms. There are five toilets and two bathrooms. There is a passenger lift in situ which serves the ground and first floors. There is a chapel within the home where religious services take place on a daily basis, for those residents who choose to participate. Care Homes for Older People Page 4 of 28 Brief description of the care home Information provided by the home prior to the inspection indicated that the fees range from 374.09 to 385.87 per week. Additional charges are made for, hairdressing, chiropody, magazines, newspapers, transport and activities. The service provider ensures that information about the service is available to prospective residents and the current residents by way of the homes Statement of Purpose, the Service User Guide and through CQC inspection reports. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star good. This means that people who use the service experience good quality outcomes. The Commission for Quality Care inspects homes at a frequency determined by how the home has been risk assessed.The inspection process has now become a cycle of activity rather than a series of one-off events.Information is gathered from a variety of sources, one being a site visit.More information about the inspection process can be found on our website www.cqc.org.uk This is what we used to write this report:We looked at information we have received about the home since it was registered. We asked for information to be sent to us before the inspection, this is called an annual Care Homes for Older People Page 6 of 28 quality assessment questionnaire (AQAA). We sent surveys to people who live at the home and to staff and Health Care professionals One inspector visited the agency unannounced. This visit lasted over four hours and included talking to the staff and the registered manager about their work and the training they have completed, and checking some of the records, policies and procedures the home has to keep. We spent time talking with people who live at the home and to one health care professional who was visiting the home. We looked at four peoples care records to check that a plan had been formulated which helped staff provide support to people according to their needs and wishes. We focused on the key standards and what the outcomes are for people who use the service. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The site visit took place on the 21st April 2009.The registered manager was available to assist throughout the visit and available for feedback at the end of the day. What the care home does well: What has improved since the last inspection? Waterlow risk asessments are carried out for those people who have been identified as being at risk of developing a pressure sore. This makes sure that any pressure sores are managed well and improvements are made, so that peoples health does not deteriate. The two commodes that were rusty have been replaced with new commodes. The home continues to work towards achieving 50 of the staff being qualified at NVQ(National Vocational Qualification) Level 2 in Care. Care Homes for Older People Page 8 of 28 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are properly assessed prior to admission, this makes sure that Jasna Gora is the right place for them to live. Evidence: The manager confirmed that information is made available to anyone interested in moving into the home in the form of a brochure and a service user guide before they move in.This information is provided to people who are considering moving to the home, relatives or to care managers from local authorities. All of the information provided has been translated into Polish, so that people who are considering moving to the home are able to understand in their own language,what is provided by the home. There have been several new admissions into the home since the last inspection visit.The manager said that people are always given the opportunity to visit the home before they make a decision as to wether they wanted to live there. Care Homes for Older People Page 11 of 28 Evidence: Four peoples files two of which had recently moved into the home were looked at in detail and confirmed good practice. Assessments were carried out before people moved into the home and contained details of every aspect of peoples daily life and health needs. Examples of the information included were daily living, social interests, and peoples long term needs. Peoples files held copies of terms and conditions or contracts.All of the files seen held contracts in them that had been agreed and signed by people living at the home and a representative on behalf of the home. People spoken to on the day said they liked living at Jasna Gora. People made positive comments such as, Very good manager. Food is like what you would have at home. It is very good living here. The home does not provide intermediate care. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal and healthcare is provided appropriately and sensitively according to individual needs.However further improvements should be made to care plans, so that they are clear for staff to follow when providing personal care, such as bathing. This makes sure that peoples personal care needs are always met. Evidence: Each person living at the home is registered with a General Practitioner. There is one GP practice involved with looking after peoples health care needs.People are able to have a female GP if they so wish. Other health care professionals are involved with peoples health care needs such as the Chiropodist,District Nurses, Community Phychiatric nurse. Peoples health care needs were recorded in their individual care plans. Most areas were well detailed. However areas such as supporting people with bathing were not aswell documented in how staff actually support people when assisting them to bathe. Care plans should have step-by-step instruction as to how people wished to be supported including when they are bathed. Care plans on the whole were well detailed and covered all areas of daily living. They also included Care Homes for Older People Page 13 of 28 Evidence: details such as risk assessments, nutriotional assessments, peoples history. Any changes to peoples health care needs are also recorded in daily records contained within their care plan. Staff were observed using disposable aprons and gloves.This maintains and promotes good levels of hygiene control. The home operates a key worker system. This means that individual care staff have responsibilities for a specific person/people, in making sure their overall care needs are consistentley being met. Care plans were written in both Polish and English. Risk assessments were in place and help identify potential risks to people, this helps the staff to put into place arrangements which may minimise the risks.Waterlow assesments for people who have been identified as being at risk of developing a pressure sore, were also contained in peoples care plans. People living at the home attend either Huddersfield Royal Infirmary or Calderdale Royal Infirmary Hospital for all A & E (Accident and Emergency) and for most out patient appointments. Two GPs told us in the surveys they returned that the home manages peoples health care needs well and peoples privacy and dignity is respected.When we asked about how the service supports individuals to administer their own medication comments made were: Usually not appropriate but i have little knowledge of this procedure at Jasna Gora. Certainly the management of patients medicines - ordering and giving patients medication - is excellent. When asked does the care service support individuals to live the live they choose? The GP said always and commented Within the limitations of their considerable disabilities. The GP also tolds us that care staff had the right skills and experience to support people who live at the home. When asked what do you feel the care service does well? The GP commented, Centred on the client. Very caring and compassionate. Always calm and dignified. Another said,caters for the residents. When asked how do you think the care service can improve? The GPs commented, It is very helpful to always have an interpreter of Polish to English available when a health care professional sees a client. Rarely the messages i wish to relay have to be deffered due to the lack of English comprehension on the afternoons. There have been no times when this presented a threat to patients care. When asked is there anything else you would like to tell us the GPs said, Jasna Gora provides excellent care. They looked after a lady in her terminal illness very well - very professional and an excellent standard of care - so that she was able to die with dignity in her own home rather than distressed in hospital where she couldnt speak English. Another GP said,When i visit there are usually many staff on,the patients i visit look well cared for,the staff are knowledgable about the patients and there are well documented notes if they need to be referred. Care Homes for Older People Page 14 of 28 Evidence: A visiting health care professional was also spoken to on the day of the site visit who was visiting the home. They said, This is a wonderful place, there are never any odours,staff are always polite, the care is good. I wish all the homes were like this one. During the morning the staff were observed as being pleasant,curteous and helpful and there was a sense that staff really cared about the people they look after.Staff spoke and interacted with people and had a cheerful banter with them.When staff spoke to people at the home they always addressed them formally by their title of Mr/Mrs/Miss etc. As this is seen as being respectful to older people by staff who work at the home. When speaking to people who live at the home they made positive comments such as: It is very good living here. Four surveys were returned from people living at the home. All were satisfied with the service they receive from the home. All surveys said that people receve the care and support they need. And that staff always listend to them and were available when needed.There were no comments made in any of the surveys as they were in English. The Commision For Quality Care were unable to send out translated surveys in time for this inspection. The home operates a monitored dosage system which is called the Nomad system. There is a policy in place for the storage and administration of medication for all staff working in the home to follow. The Medication Administration Records show that everyone receives their medication as prescribed. Records were up to date and well maintained. Medication seen in the home was securely stored in a locked drugs cabinet. Controlled drugs held were stored appropriately and records were maintained as required. All staff that administers medication in the home have been provided with medication training. Care Homes for Older People Page 15 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home have the opportunity to participate in some activities and are supported by staff to carry these out. This area could be improved by looking at introducing more varied actvities to suit peoples individual needs. Evidence: People who live at Jasna Gora have the opportunity to participate in some activities such as,people had recently made cards for Easter which were on display in the lounge.The manager said that they did things like read to people in the lounge,play bingo and do gentle excercise.People have access to Polish newspapers and Polish television which is by satellite.There is a mass every morning and at 5.00pm each day that are held in the homes chapel.On the day we visited there was no evidence of any planned activities taking place.The home now has a people carrier to take people out, however as yet people who live at the home had not wanted to go out on trips anywhere. The home keeps a log of activities that people do.The manager said that visitors are able to visit the home at anytime. Two surveys returned from people living at the home said that there were always activities, two surveys said usually. Surveys returned from staff also commented about the lack of time they have to spend with people. Comments made were Where as the physical needs of the resident are met Care Homes for Older People Page 16 of 28 Evidence: there is a limited time available to address the psychological needs of the resident. There is a lack of Quality Time - Time to engage in conversation, time to listen,time for activities. Mealtimes were discussed with the manager on the day of the visit. Menus seen were planned weekly as to what people wanted and what was in season. Menus were varied, and nutritionally balanced. Menus reflected traditional Polish meals that people would have had at home. The lunch seen on the day of the site visit looked appertising and people were observed as enjoying their lunch.The manager said that the home caters for special diets such as diebetics. Staff were available and helped people in a dignified manner and the atmosphere was calm and relaxed without people being rushed. People who were slow to eat their meals were oserved being assisted by staff and taking their time to finnish their meal.This means that peoples experience at mealtimes is always a pleasant one. People spoke highly about the food provided by the home and made comments such as, Food is like what you would cook at home. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have access to an effective complaints procedure,however people are not neccesarily always protected from harm due to the lack of safeguarding training by staff. Evidence: A comprehensive complaints procedure is followed and is made available to people and any other interested parties. The complaints procedure was on display on the information board in the home and a copy was also in each individual persons file.The home has not received any formal complaints. No complaints have been received by the Commision For Quality Care. People when spoken to and on the surveys returned were clear as to whom they would speak to if they had any concerns or worries. There is a policy and procedure with regard to safeguarding adults and the procedure to take if there is a suspicion of abuse.The manager demonstrated a good awareness of this.However there was no evidence that staff have received any training in adult protection and safeguarding issues. The home needs to give this priority in addressing this form of training.This makes sure that the home is clear as to what staff do when an allegation of abuse is made and what the protocols are that they need to follow. This will also make sure that the people living at Jasna Gora are always protected from harm. There have been no allegations regarding safeguarding made to the home or to the Commission for Quality Care. Care Homes for Older People Page 18 of 28 Evidence: Appropriate recruitment procedures are followed, with references and Criminal Records Bureau CRB checks made to reduce the risk of unsuitable people working in the home. Peoples finances were found to be appropriatly managed with receipts being obtained for all purchases made. Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean, comfortable and safe home that is decorated and furnished to a good standard. Evidence: The home provides accommodation for people that is based on two floors.This includes a lounge and dinning area on the ground floor.There are sufficient toilets and bathrooms to meet the needs of people living at the home. Peoples rooms on the first floor are accessed by the use of a passenger lift or stairs. Peoples bedrooms were seen which had been personalised with all their possessions. The manager said they had brought some of their own furniture.The home was spotlessly clean in all of the communal areas,the kitchen was also clean and everywhere was free from odours. There were soap dispensers discreetly fitted in toilets and bathrooms.This maintains and promotes good levels of hygiene control.The home was decorated to a good standard through out. People living at the home said that the home is always fresh and clean. A visiting health care professional said that the home was always clean and commented,This is a wonderful place, there are never any odours,staff are always polite, the care is good. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staffing levels, proper recruitment procedures meant that peoples needs were on the whole being met. However due to the lack of training for staff regarding fire safety and safeguarding, could potentially put people at risk. Evidence: Staffing levels were sufficient for meeting the needs of people. The duty rota showed that there are usually two members of care staff on duty both in a morning and afternoon.This does not include the registered managers hours.The home also employs ancilliary staff which includes a domestic, a cook and a handypersons hours. The staff records of four staff were looked at.These showed that all the necessary pre employment checks had been carried out prior to the new workers starting in post.All records showed completed application forms, two written references, CRB (Criminal Record Bureau) checks had been obtained. The home provides all the mandatory training that is required.A range of other training has been completed by staff such as first aid,moving and handling,fire,dementia care and medication.However staff have not received safeguarding training. The manager was advised to look at the home providing this training to make sure that the people at the home are always protected. The manager has arranged for the staff to have some fire training in the next few weeks. However looking at fire records it would appear that staff do not receive as regular fire training that is required. The manager was asked to contact their local fire Care Homes for Older People Page 21 of 28 Evidence: service and ask for advice as to how often staff should have fire training. The National Vocation Qualification Level 2 (NVQ) training has been completed by two staff at the home.NVQ Level 3 has been completed by two staff.One person is currently completing their NVQ Level 2.The registered manager has almost completed her Registered Managers Award NVQ level 4 in Care. Staff confirmed in the surveys they returned to us, that they received regular supervision. Records of supervision were seen at the site visit to the home. Staff commented positively about the support they receive from the registered manager. Staff made comments such as: Adequate training has been provided through out my employment at the home. The manager is available for staff to discuss any issues concerning them. When asked are there enough staff to meet the individual needs of people, most staff said usually. Comments made were, Where as the physical needs of the resident are met there is a limited time available to address the psychological needs of the resident. There is a lack of Quality Time Time to engage in conversation, time to listen,time for activities. Staff when asked what does the service do well? They made comments such as: Take care the safety and natural needs of residents. The service provides a very good level of care. As the staff are bi-lingual and they are able to communicate well with the residents, who do fluctuate between Polish and English when expressing their needs. It can be said with certainty that all required information,policies and procedures concerning the residental home are well defined,covering the care for the residents,safety of residents etc. Also the duties of staff are well defined according to guidelines. When staff were asked what the service could do better? Staff said, The staffing levels could be reviewed. Care staff should concern themselves with caring for residents and not be given added duties to cover lack of domestic support. Above all it is essential to put the individual requirements of the resident first and foremost, in order that there is a greater possibility for staff to treat the residents as individuals, addressing their specific requirements such as conversation, walking together etc. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a well managed home in which their needs and wishes are put first. Evidence: The registered manager has worked at the home for sometime now. She speaks both Polish and English and therefore is able to communicate effectively to people who live at the home as well as their relatives, other professionals and the staff. The home has a good and effective management team in place.The ethos of the home is open and positive.People who use the service and staff all commented highly about the home. Regular staff meetings are held and minutes are taken. All accidents are recorded as required and an accident book is maintained in line with the requirements of Data Protection. Peoples finances were checked at this site visit and evidence was that their financial Care Homes for Older People Page 23 of 28 Evidence: interests are safeguarded by the systems the home has in place. Information provided from the AQAA Annual Quality Assurance Assessment and the examination of selected health and safety documents show that regular checks to electricity and gas and fire safety equipment are regularly undertaken. Comprehensive Quality Assurance systems are in place and the home is audited regularly by the registered provider. The home carried out a Quality Audit in February 2009 and questtionaires were given to people living at the home and their relatives.They have produced a report which details the findings from the audit. Comments made from people who live at the home and health care professionals were all positive. Comments made by staff were also generally positive with veiws on how the home could improve further. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 18 13 The registered provider 07/08/2009 must make sure that all staff working at the home have up to date safeguarding training. This will make sure that people living at Jasna Gora are protected from harm. 2 38 23 The registered provider must consult with the fire authority in making sure that staff have the required fire training that is neccessary. This makes sure that people living at Jasna Gora are always safe. 07/06/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 Care plans should be updated to reflect how staff at the home make sure that they meet the personal care needs of Page 26 of 28 Care Homes for Older People people.This includes how staff actually support people to have a bath. This makes sure that staff meet peoples needs when assisting them with personal care such as bathing. 2 12 The home needs to look at ways they can improve the activities that are available to people living there. This will improve the quality of life for people at Jasna Gora. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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