Inspection on 29/03/07 for Jubilee Court

This inspection was carried out on 29th March 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Jubilee Court 22/11/05

Jubilee Court 21/06/05

Jubilee Court 01/12/04

Jubilee Court 08/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Jubilee Court 1-5 Eversley Road Bexhill-on-sea East Sussex TN40 1EU Lead Inspector Helen Martin Key Unannounced Inspection 29th March 2007 3:00 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 Jubilee Court DS0000021240.V313148.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. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee Court Address 1-5 Eversley Road Bexhill-on-sea East Sussex TN40 1EU 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) 01424 211982 01424 224677 jubileecourt@trial-link.com Trial Link Ltd Mrs Julie Smith Care Home 29 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (29) of places Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the maximum number of service users to be accommodated is twenty nine (29). Service users must be older people aged sixty five (65) years or older on admission. Only service users with mild or moderate past or present mental health needs may be admitted. Current service users being accommodated by virtue of old age only (over 65 years) may continue to reside at the home. 22nd November 2005 Date of last inspection Brief Description of the Service: Jubilee Court can provide care and accommodation for up to twenty-nine older people either with or recovering from a mild to moderate mental health problem. The home’s registration changed in May 2005 and transition to caring solely for those with mental health needs was planned to be slow in order to safeguard existing residents, some of whom continue to be accommodated by virtue of old age only. Jubilee Court is located close to the town centre of Bexhill within easy reach of the sea front, railway station, other public transport links, shops and the usual town amenities. Trial Link Ltd owns the home. A passenger lift gives access to residents’ accommodation over three floors. There are twenty-one single and four double bedrooms, fourteen of which have ensuite facilities. Double rooms are only used for married couples or partners. Communal space includes two lounges, a dining room and a garden. There are some private parking bays to the rear of the property with time-limited roadside parking nearby. The home has an organisational structure, which includes a manager, deputy manager, assistant manager, three senior staff and care workers who, operating a roster, give twenty-four hour cover. Ancillary staff are employed for catering and domestic duties. Current fees for the home range from £322.40 to £685.75 per week. Full information about the fees payable, the service provided, the home’s Statement of Purpose and the latest inspection report by the CSCI are available from the manager. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on 29th March 2007 and included talking with the owner, the manager, one member of staff and three people who live in the home. Some judgements about the quality of life within the home were taken from observation and conversation. Some records were looked at. A tour of the house and garden was undertaken. A completed pre-inspection questionnaire from the home and ten postal surveys from residents have been received. These have been used within the inspection process and information has been included within this report where appropriate. Currently there are twenty-five residents accommodated. All shared rooms are currently used for single occupancy. Comments made by residents spoken with at the time of this visit included: ‘The home is clean’ ‘I like my room’ ‘People are kind’ ‘Staff are not rude and very nice and respect my privacy’ ‘I have a good keyworker’ ‘Staff come quickly if you use the buzzer’ ‘Medication is on time’ ‘I can choose when to go to bed’ ‘I enjoy playing bingo, reading and watching TV; I don’t like playing games’ ‘I’m seeing my relative this week’ ‘I couldn’t fault the food, it’s marvellous’ ‘The laundry is quick ‘Staff have fire drills and tests every so often and the door automatically closes’ ‘I have no objections’ ‘I have no complaints’ Comments received from residents in postal surveys included: Do the staff listen and act on what you say? – ‘Not always, (I) am being compared to someone else…but they didn’t have my problem’ One resident away from the home for a while ‘…wasn’t visited by anyone from the home except to be assessed…’ to come back. ‘Always the same meals’ What the service does well: Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 6 Individuals are given the information they need before they decide to move into Jubilee Court. Procedures are in place to ensure that the home is suitable to meet prospective residents’ needs. Individuals benefit from living in a home, which is run in their best interests by appropriately supervised staff and a competent manager. They enjoy living in a clean, comfortable, warm and homely environment. Residents are treated with respect. Arrangements are in place to maintain their privacy and dignity. Individuals benefit from sufficient numbers of appropriately trained staff who care for, understand and anticipate their wishes. Staff are provided with training to meet residents’ personal, health and social care needs. Individuals’ views are listened to. Residents enjoy their lifestyle within the home and are able to keep in contact with their family and friends if they wish. They benefit from a varied diet. What has improved since the last inspection? What they could do better: Individuals would be better protected by improvements to the systems for residents’ monies, staff recruitment, the administration of medication, the fire alarm, hot food and record keeping. Some repairs and additional radiator covers would enhance their safety. Residents’ would benefit from their personal, health and social care needs being better reflected in care plans and records. They would also benefit from the action taken following a complaint being better reflected in records. Additional choice for some meals would improve their quality of life. The manager completing their management qualification may enhance the smooth running of the home. Jubilee Court DS0000021240.V313148.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. The summary of this inspection report can be made available in other formats on request. Jubilee Court DS0000021240.V313148.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 Jubilee Court DS0000021240.V313148.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are given the information they need before they decide to move into Jubilee Court. Procedures are in place to ensure that the home is suitable to meet prospective residents’ needs, although they would benefit from this being better reflected in records. EVIDENCE: Written information is available about the home within a statement of purpose and service users’ guide. Previous inspection identified that these documents were of a good quality, reflected the change from caring for older people to older people with mild to moderate mental health needs and provided guidance for prospective residents about the facilities and service provided by the home. During this visit it was said that, although reviewed since, it had not been necessary to make any changes to the documents. Postal surveys received Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 10 from residents all indicated that they were provided with enough information about the home before they moved in and a contract. Contracts detail the terms and conditions of accommodation within the home. Residents are assessed before they move in, in order to ensure that the home is suitable to meet their needs. Assessments undertaken by the home are recorded. Discussion took place around information specifically to do with prospective residents’ mental health needs. The owner explained that they intended to introduce a new format, which would have the facility to record this in greater detail. Records seen confirmed that Social Services also carry out assessments. The manager stated that residents were able to visit Jubilee Court prior to moving in and after they did, had a month’s trial period to ensure that they liked the home and that their needs could be met. This was confirmed by residents’ contracts. The manager demonstrated a good understanding of the needs of individuals that the home could and couldn’t meet. Jubilee Court can provide care and accommodation for up to twenty-nine older people either with or recovering from a mild to moderate mental health problem. The owner confirmed that, although the home’s registration changed in May 2005, transition to caring solely for those with mental health needs was planned to be slow in order to safeguard existing residents; therefore some residents continue to be accommodated by virtue of old age only. The manager assured the inspector that the home continued to meet the needs of one resident, under the age of sixty-five, who had been living in the home for some years. The home does not provide intermediate (rehabilitative) or respite care. Jubilee Court DS0000021240.V313148.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect. Arrangements are in place to maintain their privacy and dignity. Residents’ personal, health and social care needs are met, although they would benefit from this being better reflected in care plans. Residents would be better protected by improvement to the procedures in place for the administration of medication. EVIDENCE: Individual plans of care are compiled for each resident; these aim to identify, amongst other things, the support required from staff to meet residents’ personal, social and health care needs. Previous inspection identified that a new format had been introduced but that continued work was required to change all plans to the new style. This visit identified that the home continues to be in the process of developing electronic care plans. Those seen, together with assessments, are not comprehensive or completed in enough detail to Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 12 give staff adequate guidelines. Previous inspection identified that not all care plans contained an assessment of risk; this visit identified that newer electronic records did not contain any. The manager was in the process of developing a plan of care for one newly admitted resident. Hand-written notes are kept of the day-to-day support provided for residents. Although the reason for one individual’s admission to the Accident and Emergency department was recorded, the treatment and outcome was not. The manager described the system for care plan reviews and how these were amended. Residents spoken with said that they are happy with the personal care they receive from staff; it was mentioned that they were helpful, respectful and responsive. The majority of postal surveys indicated that residents always receive the care and medical support they need, whereas a minority stated that this was usually the case. Records seen confirmed that a range of professionals are accessed to help meet residents’ health care needs, such as GPs and District Nurses. Specialist professionals, including Community Psychiatric Nurses, support staff in meeting residents’ mental health needs. Staff support residents with appointments. Comprehensive information was available for staff regarding continence management. Residents are weighed monthly and their food and drink choices are recorded. Staff manage residents’ medication for them; an easily monitored system is used. Medication is stored securely and appropriate facilities and records are used for controlled drugs. Medication requiring refrigeration is kept in a designated fridge, although temperatures are not monitored or recorded. The pharmacy supplying residents’ medication does not give the home pre-printed administration records to complete. Currently the manager produces their own on a computer; some entries are handwritten. There are no staff signatures or written confirmation by the prescribing professional to confirm that information has been copied correctly. Although residents confirmed that they receive their medication on time, records do not include the specific time of the dosage given, only the time of day, such as breakfast, lunch etc. Not all handwritten entries include the amount of the dose required. Records are not kept with photographs of residents for identification purposes. No written guidelines are available for the administration of medication needed on a ‘when required’ basis. The manager said that medication was checked on receipt by the home, although not all checks are recorded. Records of medication returned to the pharmacy are signed by staff but not by the pharmacy. The manager stated that all staff had received training in medication, including specific training from the District Nurse for the administration of insulin; a record of staff signatures is maintained. Reference books about medication are available. The manager has obtained recent guidelines from the Royal Pharmaceutical Society regarding the administration of medication in care homes. Residents spoke positively of the staff and felt that their privacy and dignity is respected. They are able to make telephone calls in private and/or have their Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 13 own landline. One resident confirmed that the system for laundry was good and fast. The manager said that they aimed to provide residents with a home for life; if possible a resident who was dying would be supported to spend their last days in the home in familiar surroundings with people they know. The manager demonstrated a good understanding of the needs of individuals and their families at this time. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy their lifestyle within the home and are able to keep in contact with their family and friends if they wish. They benefit from a varied diet, although additional choice for some meals would improve their quality of life. EVIDENCE: Residents are able to go out when they wish; some are independent, whilst others need staff support; they confirmed that the routines of the home are generally flexible. An activities organiser is provided three times a week. The manager said that residents could take part in hair and beauty sessions, shopping, tea out, music, games, softball and exercises; an outside company comes into the home to involve residents with plays and singing. Those spoken with enjoyed their lifestyle and described their daily activities and interests as bingo, reading and watching television; not all enjoyed participating in games. The vast majority of postal surveys received indicated that there are always activities to take Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 15 part in. At the time of this visit residents seen were reading, watching television and enjoying a jigsaw. The manager explained that they continued to develop activities within the home that residents would enjoy. Religious ministers provide Holy Communion regularly for some residents, in addition monthly prayer and singing groups are held. Residents are encouraged to keep in contact with their relatives and friends if they wish. Visitors are welcome in the home at any reasonable hour. Some residents spoken with confirmed that they enjoyed visits from members of their family. Residents spoken with said the quality of the meals was very good. Postal surveys received indicated that whilst four residents always liked the meals, five usually did and one only sometimes, one comment stated ‘always the same meals’. The menu is planned in advance and showed a variety of meals including a choice of hot and cold food for breakfast and supper. Alternatives to the main meals however are limited; options available include either a salad or omelette. Individuals’ choices are recorded. The manager explained that residents told staff their likes and dislikes and therefore they didn’t need to ask for them. Specialist diets can be catered for, such as diabetic. It was said that residents could have drinks and snacks whenever they wish. A mineral water dispenser is provided in the home. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The views of residents are listened to, although they would benefit from the action taken following a complaint being better reflected in records. Individuals would be better protected by improvements in the systems for residents’ monies and staff recruitment. EVIDENCE: At the time of this visit, residents were at ease talking with staff. Residents spoken with had no complaints about the home. The vast majority of comments received through postal surveys indicated that residents know how to make a complaint and who to talk to, that they are listened to and action is taken, although a minority of responses did not agree with this. The manager said that complaints are taken seriously and looked into. These are recorded, although some investigations and outcomes are not. It was stated that all staff are trained in adult protection and records confirmed this. The manager described the procedure for a previous incident, including contacting social services. The inspector was assured that in future, this would always been done for any allegation made. It was evident during this visit, that residents are not fully protected by the systems in place regarding residents’ Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 17 monies and staff recruitment. This has been mentioned in detail elsewhere within this report. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in a clean, comfortable, warm and homely environment. They would be better protected by some repairs and additional radiator covers. EVIDENCE: Jubilee Court is comfortable, warm and homely. All areas seen were clean and this was confirmed by comments received from residents. Since the last inspection, refurbishment of the kitchen has been completed and a summerhouse provided in the garden. It was noted that two areas of tiling in the downstairs bathroom are damaged and in need of repair/replacement. The manager said that work had not yet commenced following previously gained planning permission to extend the lounge, dining room and kitchen. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 19 Communal areas are adequately decorated and furnished. The home currently provides two lounges, a dining room and a garden. Residents are accommodated over three floors in twenty-one single and four shared bedrooms, the latter only being used for married couples or partners. Currently all rooms are used for single occupancy. Individual rooms are personalised, reflecting the occupant and containing personal effects. All residents spoken with liked their accommodation. Previous inspection identified that there were sufficient bathrooms and showers within the home to meet residents’ needs; bath hoists are provided. It was observed that access to one communal bathroom is via three or four stairs, although there is flat access to another bath and walk-in shower room. In addition, fourteen bedrooms have ensuite facilities. The home’s pre-inspection questionnaire states that, since the last inspection additional facilities of a walk-in shower and a bedroom ensuite shower have been installed. Access to the home is flat and the manager said that a slope would be provided for the garden when the extension to the home is undertaken. There is a passenger lift to the first and second floors. Grab rails, adaptations and ramps to aid mobility are situated at strategic points throughout the home. The home is well lit and naturally ventilated. The home has a gas central heating system with radiators in all rooms. Previous inspection identified that these could be controlled by means of thermostatic valves and that a programme of fitting radiator guards was underway. During this visit, the manager assured the inspector that all radiators that could place residents at high risk of harm had been covered. The owner said that guards for all remaining radiators would be provided shortly. Hot water outlets are fitted with valves to regulate temperature and prevent scalding by residents, one tested by hand was found to be an appropriate temperature to the touch. The manager stated that hot water temperatures were tested and recorded monthly. The home is clean and hygienic throughout and staff are trained in infection control procedures. The home’s laundry, which is in the cellar, is suitably equipped. Care staff undertake residents’ personal laundry, where as the home uses a professional service for bed linen. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from sufficient numbers of appropriately trained staff, who care for, understand and anticipate their wishes. Residents would be better protected by improvements to the procedure in place for staff recruitment. EVIDENCE: All residents spoken with said the staff were nice and kind; one said that their keyworker was good. The owner, manager and staff are committed to their role. Staffing levels during these visits were adequate and records seen confirmed this. Residents spoken with said that staff responded quickly to call bell alarms. Responses from postal surveys indicated that staff are either always or usually available when they need them. The home has an organisational structure, which includes the manager, deputy manager, assistant manager, three senior staff and care workers. There are usually four care workers on duty during the morning, three in the afternoon and two awake at night. Although there are no vacancies, the home is currently in the process of recruitment for an additional member of staff. No agency workers are used. Ancillary staff are Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 21 employed for catering and domestic duties, although care staff undertake residents’ personal laundry tasks. The staff recruitment procedure in place within the home aims to protect residents. However, records seen evidenced that although most preemployment procedures had been undertaken appropriately, full employment histories and photographic identification were not checked. One member of staff, employed for some time, had provided a Criminal Records Bureau (CRB) check from previous employment; Jubilee Court had not applied for a new one. The manager assured the inspector that this would be undertaken as soon as possible, together with a check against the Protection of Vulnerable Adults list (POVA First). Although the staff application form includes the facility to disclose police convictions, this does not include any cautions. In addition, the form includes the facility to provide information about an applicant’s physical health, but not mental health. After appointment, all new staff are provided with induction training. Since the last inspection, this has been reviewed and developed. New records are now in place, which contain good detail. A central training record for all staff has now been developed. This indicates that staff are receiving a range of training around meeting the needs of older people, including those with a past or present mental health problem. The manager said that the home used the services of a qualified trainer who provided some training, including report writing, key working, risk assessment, accident prevention, communication, confidentiality, care planning and various issues related to mental health; in addition, other courses include medication, adult protection, manual handling, food hygiene, infection control, fire, health and safety and first aid. Records show that over 50 of staff are trained to the required national level; ten out of a total of fifteen staff members have obtained an NVQ qualification at level 2 or 3. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home, which is run in their best interests by appropriately supervised staff and a competent manager, although this could be improved by the latter completing their qualification. Individuals would be better protected by improvements to the systems for residents’ monies, the fire alarm, hot food and record keeping. EVIDENCE: The manager is experienced and knowledgeable about the needs of older people who require residential care. They have worked at Jubilee Court within different capacities for ten years. The manager explained that, since the last Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 23 inspection, they had completed an NVQ level 4 qualification, which included mental health issues; it was said that they had now commenced the Registered Manager’s Award. The atmosphere of the home is open and inclusive and individuals spoken with confirmed this. There is discussion on a day-to-day basis. Regular staff meetings and one-to-one supervision take place, which is recorded. The regularity of staff supervision has increased since the last inspection. The home has their own quality assurance system, which includes questionnaires being sent to residents and their relatives. Since the last inspection regular visits to the home have been undertaken and recorded by the owner, some of which were seen during this visit. The manager keeps up to date with information on the CSCI website. The home provides a range of written policies and procedures. The home keeps small amounts of cash on behalf of some residents, which is stored individually. Transaction details are recorded, although these are not signed by staff making the entries or by residents when receiving cash. Not all receipts for expenditure are kept with records. Three balances were checked, but only one tallied with accounts kept. The manager explained that money had been taken out to buy items for the residents concerned, the change had not yet been returned nor entries in records made. It was evident that the system in place is not fully accountable. Residents’ personal property is recorded appropriately. Electronic records are password protected and backed up regularly. Accidents and incidents are recorded, although not all outcomes and audits by the manager are. The manager assured the inspector that all significant events would be notified to the CSCI in future, it was evident that this had not always been done in the past. Although written appropriately, complaint and health and social care professionals’ records are kept in a bound book, which compromises data protection. Records seen generally indicated the regular testing and maintenance of systems and equipment within the home, with the exception of fire alarm checks. Although residents spoken with stated that regular tests took place, records evidenced that over the past few months these had been undertaken monthly and not weekly. Issues regarding the recording of fire alarm tests were identified during previous inspection. Fire drills take place regularly. The manager assured the inspector that, a fire door in a resident’s room now closes and that, since the last inspection, all fire doors left open have been fitted with a closing device should the alarm sound. The manager explained that, following recommendations made by the Fire Officer in October 2006, the home is in the process of upgrading the fire alarm system; it was stated that the home was working with the Fire Authority in order to address all issues identified by 6th December 2007. Environmental room and fire audits take Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 24 place on a monthly basis. Environmental and fire risk assessments have been undertaken. The manager assured the inspector that three recommendations made by the Environmental Health Officer in April 2006 had been addressed and that they were in the process of following up issues from a subsequent visit two weeks ago. It was said that a cleaning schedule had been developed. The manager assured the inspector that they would shortly introduce the testing and recording of hot food temperatures. It was mentioned that fridge and freezer temperatures are checked and recorded regularly. Other records looked at together with staff training have been mentioned previously within this report where appropriate. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 25 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 2 3 2 2 Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP37 Regulation 15 Requirement …the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan…as to how the service user’s needs in respect of his health and welfare are to be met. In that, in order to evidence that residents needs are being fully met: 1. The transfer of all relevant information from the old format care plans to the new must be completed. 2. All care plans and assessments must be comprehensive and completed with enough detail in order to give staff adequate guidelines. 3. Assessments of risk must be put in place for all residents. This requirement has been repeated from previous Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 27 Timescale for action 25/05/07 inspection dated 22nd November 2005. 2 OP9 13(2) The registered person shall make 11/05/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. In that, in order to fully protect residents: 1. The temperature of the designated medication fridge must be monitored and recorded. 2. All medication administration records must include the time and the amount of the dosage. 3. All checks on medication received by the home must be recorded. 3 OP18 OP29 OP37 19(1)(b) The registered person shall not employ a person to work at the care home unless…(they have) obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2 In that, in order to fully protect residents: 1. Applicants for employment must provide a full employment history, together with a satisfactory written explanation of any gaps in employment. 2. Photographic identification of applicants must be checked wherever Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 28 11/05/07 possible. 3. Jubilee Court must apply for a Criminal Records Bureau check for all applicants for employment. 4. The manager must urgently apply for a CRB and POVA First check by 24/04/07 for one employee, as discussed at the time of this visit. 4 OP18 OP35 OP37 17(2)(3) (a) The registered person shall maintain in the care home the records specified in Schedule 4…(and) shall ensure that (these)…are kept up to date… Schedule 4:9: A record of all money…deposited by a service user for safekeeping or received on (their) behalf…shall state the date on which the money…(was) deposited…received…, returned to the service user or used, at (their) request…, on (their) behalf and…the purpose for which the money…(was) used… In that, in order to evidence that residents are fully protected: An urgent review of monies held by the home on behalf of residents must be undertaken in order to develop a fully accountable system. This must include: 1. All cash balances must tally with written accounts. 2. All cash taken by staff for Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 29 27/04/07 purchases on residents’ behalf must be recorded. 3. All receipts for expenditure must be kept with transaction records. 4. The owner should audit this review. 5 OP38 23 The registered person shall…take 27/04/07 adequate precautions against the risk of fire…(and) make adequate arrangements for…testing fire equipment, at suitable intervals In that, in order to fully protect residents: The home must liaise with the fire authority to ensure that the fire alarms are tested at suitable intervals. This requirement has been repeated from previous inspection dated 22nd November 2005. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 OP7 OP37 1. Prospective residents’ mental health needs should be fully evidenced in records. 2. The treatment and outcome of any residents’ Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 30 Good Practice Recommendations It is strongly recommended that, with regard to care plans: hospital admissions should be fully evidenced in records. 3. Health and social care professionals’ records should be kept in a manner that does not compromise data protection. 2 OP9 It is strongly recommended that, with regard to medication: 1. The home should consult with their supplying pharmacy to develop a safe method of recording the administration, receipt and disposal of medication. 2. Two members of staff should sign all medication records produced by the home, whether on a computer or handwritten, as accurate and written confirmation by the prescribing professional should be available. 3. The home should consult with their supplying pharmacy regarding the provision of appropriate MAR charts based on the prescriptions of the visiting GP and also the identification of people using the service. 4. Records should evidence that staff are aware of guidelines for the administration of medication needed on a ‘when required’ basis. 3 OP15 It is recommended that, with regard to meals, a review should be undertaken to ensure that: 1. The home is proactive in asking for and recording residents’ food likes and dislikes. 2. Alternatives to the main meals are varied. 4 OP16 OP37 It is strongly recommended that, with regard to complaints: 1. Records should evidence all complaint investigations and outcomes. 2. Complaint records should be kept in a manner that does not compromise data protection. 5 OP19 It is recommended that the two areas of damaged tiling in DS0000021240.V313148.R01.S.doc Version 5.2 Page 31 Jubilee Court the downstairs bathroom should be repaired and/or replaced. 6 OP25 It is strongly recommended that the owner complete their stated intention to provide covers for all radiators that need it as soon as possible. It is strongly recommended that, with regard to staff recruitment: 1. The staff application form should include the facility to self-disclose any police cautions. 2. Applicants for employment should provide a statement as to their mental health, in addition to their physical health. 8 OP31 It is recommended that the manager should fulfil their stated intention to complete the Registered Manager’s Award as soon as they are able. (A requirement was made regarding the manager’s qualifications during previous inspection dated 22nd November 2005) 9 OP35 It is strongly recommended that, with regard to monies held by the home on behalf of residents: 1. Staff making entries should sign transaction records. 2. Residents should sign for cash received. 10 OP37 It is strongly recommended that, with regard to accidents and incidents: 1. The outcomes of all accidents and incidents should be recorded. 2. Accident and incident audits by the manager should be recorded. 11 OP38 It is strongly recommended that the manager should complete their stated intention to fully address all recommendations made by the Fire Authority by 6th December 2007. It is strongly recommended that the manager should complete their stated intention to introduce the testing DS0000021240.V313148.R01.S.doc Version 5.2 Page 32 7 OP29 OP37 12 OP38 Jubilee Court and recording of hot food temperatures. Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Jubilee Court DS0000021240.V313148.R01.S.doc Version 5.2 Page 34 - 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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