The inspection took place on 11 August 2014. Two adult social care inspectors and an expert by experience carried out the inspection. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert had experience of older peoples care and was also able to speak Polish which was the first language of the majority of people who used the service.At the time of this inspection Jasna Gora was providing care and support to twelve people. We spoke with seven people living at the home and reviewed information from four surveys submitted by relatives to obtain their views of the support provided. We also spoke with a visiting healthcare professional. In addition, we spoke with the home manager and two members of care staff, a cook and a domestic staff about their roles and responsibilities.
We considered all the evidence against the outcomes we inspected to help answer our five key questions; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?
Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.
Is the service safe?
We found all parts of the home clean with no traces of any unpleasant odours.
People who used the service told us they were treated with respect by staff and that they felt safe living in the home.
Safeguarding procedures were robust and staff understood their role in safeguarding the people they supported.
Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.
We found risk assessments had been undertaken to identify any potential risk and the actions required to manage the risk. This meant that people were not put at unnecessary risk but also had access to choice and remained in control of decisions about their lives.
CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, relevant policies and procedures were in place. Appropriate staff had been trained to understand when an application should be made, and how to submit one.
People were, in the main, protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. One staff practice that may affect the safety of people during the administering of medication was identified and was discussed with the manager. The manager gave assurances that this issue would be addressed and staff would be given further training and support.
Is the service effective?
People and their relatives told us they were actively involved in making decisions about care and support. People's health and care needs were assessed with them and their representatives, and they were involved in writing their support plans.
Healthcare professionals we spoke with said that the staff worked well with them and followed instructions to promote and uphold people's health and welfare. They said, 'we request things that need to be carried out for residents and staff are very good at following these instructions, fluid charts and pressure area care records are always kept up to date.'
Staff were provided with training to ensure they had the skills to meet people's needs. Staff were provided with formal individual supervision and appraisals to ensure they were adequately supported and their performance was appraised. The manager and provider were accessible to staff for advice and support.
During our visit, we found people were provided with the support they needed. We found staff knew people well and were aware of their individual preferences.
Is the service caring?
We observed warm and respectful interactions between staff and people who used the service. During our inspection we observed smiling faces of both staff and people.
People who used the service were positive about the staff and felt they were known personally to them. Comments from people included, 'I am very happy here', 'staff are very good', 'no worries at all' , 'it could not be any better as we have everything we need', 'we have very good staff', 'it's very clean' and 'I would highly recommend this home to others.'
Relatives said, 'we are delighted with the care' and 'the home has a strong family ethos, very caring.'
Healthcare professionals said, 'this is one of the best homes we go into, people are treated with the utmost respect', 'no worries at all' and 'this is a home that, if we ever needed to, my colleagues all agree we would go into.'
Is the service responsive?
People were able to join in with a range of activities. We saw care workers spending time with people on a one to one basis.
People spoken with said they had never had to make a complaint but knew how to make a complaint if they were unhappy. We found appropriate procedures were in place to respond to and record any complaints received. People could be assured that systems were in place to investigate complaints and take action as necessary.
Is the service well-led?
The service worked well with other agencies and services to make sure people received their care in a joined up way.
The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.
People spoken with said they were invited to attend a 'residents meeting' which was held every month.
Staff had regular meetings with the manager and were kept updated about any information they needed to know about the service. This helped to maintain consistency in the running of the service and to ensure staff were aware of relevant information.
The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. People who used the service were asked for their views about their care and support and these were acted on.
We saw evidence that the provider carried out annual satisfaction surveys. Feedback was analysed and the provider, took appropriate action. We saw that the results of the surveys were very positive.