Inspection on 11/11/05 for Jubilee Gardens

This inspection was carried out on 11th November 2005.

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 Gardens 25/04/07

Jubilee Gardens 18/07/06

Jubilee Gardens 15/06/05

Jubilee Gardens 29/12/04

Jubilee Gardens 07/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Jubilee Gardens 26 Wyegate Close Castle Bromwich Birmingham West Midlands B36 0TQ Lead Inspector Sean Devine Unannounced Inspection 11th November 2005 08:40 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 Gardens DS0000036766.V265976.R01.S.doc Version 5.0 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 Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Jubilee Gardens Address 26 Wyegate Close Castle Bromwich Birmingham West Midlands B36 0TQ 0121 730 4560 0121 730 4569 jubilee.gardens@craegmoor.co.uk 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) Craegmoor Healthcare Care Home 50 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (12) of places Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The number of persons for whom personal care (DE(E)) is provided at any one time shall not exceed 13. The number of persons for whom nursing care (DE(E)) is provided at any one time shall not exceed 25. One named service user under the age of 65 years with dementia may reside at the home. Where people with personal care needs and people with nursing care needs are cared for together in a single unit, staffing levels for units for people with nursing care will apply. The number of persons for whom transitional care (OP) is provided at any one time shall not exceed 12, of whom three may be under 65 years of age. The Transitional Unit must be staffed separately to the other units in the home. A minimum of 336 care staff hours (excluding qualified staff) must be provided each week. There must be 24 hour RGN cover at all times. Sensitive and regular reviewing mechanisms must be in place to increase staffing levels when the majority of service users have high dependency needs. Service users admitted to the Transitional Unit must be discreet and clearly distinguished from the other units, and must not at any time be cared for in any of the other units in the home. Staffing of the care units and the day centre must be discreet and clearly distinguished from each other. Mechanisms must be in place to support staffing in both areas without detriment to either service. 15/06/05 5. 6. 7. 8. Date of last inspection Brief Description of the Service: Jubilee Gardens is a purpose built home situated in Smiths Woods in Castle Bromwich. It has extensive secure gardens on a level ground, making access for residents easy, the gardens are beginning to mature. The home has facilities for 50 residents in total, 13 requiring personal care, 25 requiring nursing care and 12 transitional care beds, some of the residents occupying permanent accommodation may also have dementia. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 5 The home has designated communal and private rooms, all bedrooms have ensuite facilities comprising of a toilet and hand washbasin. The bedrooms are decorated to an acceptable standard, and residents can personalise their own rooms if they wish. Two small lounges have been re-allocated for staff use, which also includes a staff training area. The home has adequate parking space and is close to the local shopping area and other local amenities. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was conducted on an unannounced basis by two regulation inspectors. The inspectors were able to meet with residents, resident’s families and staff at the home. Records pertaining to service delivery and care provided were sampled including health and safety and communal areas and some residents rooms were viewed. Residents care plans were sampled on Windsor unit (residential) and upon Kensington unit (nursing). The medicine management was sampled on three units, Balmoral, Windsor and Kensington. What the service does well: What has improved since the last inspection? Residents have been provided with a contract detailing the terms and conditions of residency. Families are being consulted about the care that is planned and offered to the residents, they are being invited to review meetings. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 7 One relative commented that staff seemed increasingly helpful and that if they had any concerns that they could go to the staff and tell them. Record keeping to include when residents see community healthcare services such as opticians and chiropodists are now well recorded and also details of specialist equipment for many residents is now recorded in care plans. Support for residents at mealtimes has improved to enable them to eat their meals within a set period of time; this has ensured that lunch is completed several hours before teatime. The nursing and care staff are now maintaining the confidentiality of the residents as they now ensure that when they discuss information about residents that this is conducted in private. The organisation has recruited a new manager who has experience of managing dementia care services and is also a dual qualified nurse. The area manager has confirmed that the organisation intend to apply to the CSCI to register the manager. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 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 Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2,3 Residents are informed of their responsibilities and those of the provider detailed within a contract. Residents are assessed; this enables the nurses to decide whether they can meet their needs. The histories and biographies of residents are not fully considered when assessing and planning care which could hinder all of their needs being met. EVIDENCE: Residents are provided with contracts detailing the terms and conditions of their residency at the home. Relatives had signed those contracts sampled and where this was not possible a statement recording why it had not been signed had been made. Residents’ files did not always include a detailed account of their life histories, developed prior to admission and ongoing for residents and care plans to reflect these needs have thus not been developed. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 10 A range of pre-admission information was available this included social services care plans and a detailed assessment of activities of daily living completed by the nursing staff. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 11 The residents are supported by well-written care plans and risk assessments. Some risk assessments are completed without prevalent risk. Healthcare assessments do not always inform staff in how to support residents and healthcare provision including medication practice is poor. EVIDENCE: Residents care plans were sampled on Windsor unit (residential) and upon Kensington unit (nursing). Care plans are in place following a detailed assessment of daily living activities. Most care plans describe to staff how they are to support each resident and also what the residents’ preferences are. However some oral health care plans did not describe how to support residents. As identified at the previous inspection some care plans describe immediate risks and should be written within a risk assessment framework with a risk management plan. The development and review of care plans in consultation with the resident and next of kin has commenced as invitations have been extended to families to be involved in the process. Most sampled care plans did describe some of the social care needs of the residents, however many did not include interests, hobbies and pastimes. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 12 Individual risk assessments had been completed in detail for each resident, a management plan to reduce the risk was included. However as identified at the last inspection many of the sampled risk assessments detailed ongoing needs and are not needed as risk assessments but must be written within a care-planning framework. On Windsor unit care plans did not describe why a resident uses an air flow mattress and cushion, with the Waterlow assessment for pressure areas identifying a low risk. Sampled residents files on both units include nutritional, moving and handling, risk of falls and Waterlow pressure area risk assessments. Some falls risk assessments had not been reviewed in excess of 18 months, and some nutritional and moving and handling assessments did not include what measures to take to reduce risks. It was a concern that the actions for one resident included removing their crutches. This action must be reviewed. The homes arrangements for medication management were looked at on three units, Balmoral, Windsor and Kensington and the following are concerns that need to be addressed: 1. 2. 3. 4. 5. 6. All dispensing labels must include clear directions. A controlled drug register must be available for each unit. Accurate stocks of medicines must be maintained. All as required medicine must have clear guidelines for staff to follow. Full sharps containers must be disposed of. Medicine Audits must be completed thoroughly and include an accurate audit of stock, where discrepancies are identified appropriate actions must be taken. 7. Residents must never be administered medication that is prescribed for other residents. 8. There must be consultation with the disposal of waste medicines contractor to ensure the home disposes of medicines safely with accurate records maintained. The sampled residents files did not in most cases include information about their likes and dislikes. Residents appear not to have been consulted in most cases in respect of their final wishes. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 15 Residents are supported to engage in activities. However it is not clear that residents choices and abilities are assessed prior to planning these activities and thus some residents may not benefit or enjoy these planned activities. EVIDENCE: There is an activities co-ordinator who works weekdays, on one of the four units each day; this is planned on a rotating basis. The activities co-ordinator has developed a four weekly programme of activity; there is a programme for each unit. Activities on the Kensington unit include craftwork (during inspection several residents were involved in making Christmas cards), sensory games (tactile balls), listening to music and sing-a-longs. Records of each resident’s involvement in activity are recorded. The activity co-ordinator advised that the programme had been developed after assessing the abilities of residents. Records of such assessments to also include interests, hobbies and pastimes were not available. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Systems and procedures are in place to enable residents and their representatives to raise and advocate for areas of concern. Staff training on adult protection is needed to fully afford protection for the residents. EVIDENCE: The complaints policy is visible on the walls in the corridors and within residents’ contracts; the policy is informative and will help guide residents and their representatives in how to make a complaint and the process the complaint will go through. Records maintained indicate there have been two formal complaints in 2005 of which one was investigated by the Commission for Social Care Inspection. The Commission has investigated two complaints in respect of meeting residents’ needs and staff practices during 2005. Certain areas of these complaints have been upheld and others have not. The home has consulted with the Commission when they have been unclear if certain incidents are reportable under POVA procedures. On three occasions in 2005 the local authority have been contacted by the home to discuss and where needed implement POVA procedures. The home has its own procedures that reflect good practice with reference to the Department of Health “No Secrets” document. Some staff have received training in protecting vulnerable adults from abuse. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 21, 22 and 26. Residents are provided with good facilities and equipment to enable them to access all areas and facilities within the home. Minor improvements are needed to ensure this is safe for all residents. EVIDENCE: The manager advised that the missing shower curtains had been replaced and that the bathrooms where there were concerns about noisy extraction fans, that these concerns had been addressed. There are spacious and well equipped toilets, bathrooms and shower rooms. The baths have a hoist lift and the showers have special chairs and grab rails. All residents have en-suite toilet facilities. The manager advised that the special support seating for a resident that was found to be damaged at the last inspection had not been replaced. However an order for four specialist seats was being made. Records seen confirm that specialist equipment to aid the moving and handling of residents is frequently checked and subject to regular servicing. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 16 Some residents rooms were viewed on both Windsor and Kensington Units, it was seen that most were clean and odour free. One room on Windsor unit requires increased attention to odour control. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28 and 30. Residents are not always supported by adequate numbers of staff that are well trained and competent to meet their needs. This means that some residents may not have their needs met appropriately and they could be put at risk. EVIDENCE: As identified at the last inspection Windsor unit is staffed by two care assistants during all day hours, one of which is normally a senior. These levels are inadequate at certain times including for example managing the personal care of residents and assisting residents with external activities such as leisure and shopping. The staffing rota does not always identify which unit staff are working upon and in what capacity. The training matrix supplied by the administrator indicated that there are forty-five care staff employed of which seventeen have completed NVQ 2 in Care or above, this represents 38 of care staff. The training matrix reflects that some staff have undertaken service specific training such as Dementia and Bereavement Care. Many staff have completed mandatory safe working practice training however it was evident that there are gaps including Fire safety, COSHH, Manual Handling and Basic Food Hygiene. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 36 and 38. Gaps in staff training and supervision indicate that the home is failing to deliver a service that is in the best interests of residents. The health and safety practices are good and are effective to promote the welfare and safety of residents. EVIDENCE: A new manager has been in post a short period of time. The manager appears to have the professional nursing experience needed to manage Jubilee Gardens and the Area Manager has previously confirmed that an application to the CSCI is to be made to register this manager. The manager advised that the representatives of residents including stakeholders have not as yet been consulted in respect of Quality Assurance, an annual report on the quality of services was not available to residents and interested parties. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 19 The manager and administrator advised that a timetable for staff to be supervised had been devised and is in the process of being implemented. At present not all staff are receiving frequent supervision to provide them with adequate support. As identified at previous inspections nursing staff have not been receiving supervision that will help maintain and develop their clinical practice. This may put residents at risk of inappropriate care. The home has a dedicated maintenance operative who has maintained clear and precise records in respect of testing and repairs to equipment such as fire alarm tests, fire drills and emergency lights. Other records indicate that the servicing of equipment including passenger lift, electrical appliances, gas, water and nurse call systems are frequently completed. Risk assessments specifically to promote fire safety are routinely reviewed, however the findings of the review are unclear. Records maintained by the administrator in respect of staff attending fire drills indicate that the drills are conducted frequently, however it is evident that not all staff attend at least two fire drills a year. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 20 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 X 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X 3 2 X X X 2 STAFFING Standard No Score 27 1 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 X 2 Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) Requirement The assessment of need including the life histories of residents must be used to develop written care plans. Previous timescale of 30/9/05 not met, this requirement is carried forward. The manager must ensure that the residents or their representatives sign all care plans and risk assessments. Previous timescale of 31/5/05 not met, this requirement is carried forward. Residents must have a care plan detailing how the home will meet their interests, hobbies and pastimes. Previous timescale of 30/04/05 not met, this requirement is carried forward. Residents must have oral health care plans that describe to staff the support residents need. Residents who are using DS0000036766.V265976.R01.S.doc Timescale for action 31/01/06 2 OP7 15(1) 31/01/06 3 OP7 15(1) 31/12/05 4 OP7 12(1) 31/12/05 Page 22 Jubilee Gardens Version 5.0 15(1) 5 OP7 13(4) 12(1) specialist equipment such as pressure relieving mattresses and cushions must have risk assessments and care plans in place. Risk assessments and the associated risk management plan must be completed for immediate risks and care plans completed for ongoing needs. Previous timescale of 31/8/05 not met, this requirement is carried forward. 31/12/05 6 OP7 15(1) 12(1) 7 OP9 13(2) All risk assessments must be reviewed at least every 6 months and following any concerns or changes. The control measures used to 31/12/05 reduce risk must be reviewed, where this includes removing walking aids when not in use, a consultation with residents and representatives must be undertaken and alternative measures considered. 31/12/05 All dispensing labels must include clear directions. A controlled drug register must be available for each unit. Accurate stocks of medicines must be maintained at all times. All as required medicine must have clear guidelines for staff to follow. Full sharps containers must be disposed of. Medicine Audits must be completed thoroughly and include an accurate audit of stock, where discrepancies are identified appropriate actions Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 23 must be taken. There must be consultation with the disposal of waste medicines contractor to ensure the home disposes of medicines safely with accurate records maintained. Residents must never be administered medication that is prescribed for other residents. The home management must ensure that information regarding the residents likes, dislikes are recorded in their files and where appropriate care is prescribed. Residents wishes in respect of care related to death and dying should also be recorded. Previous timescale of 31/8/05 not met, these requirements are carried forward. The home management must ensure that all care staff and qualified staff, have training in death and dying and bereavement care. Previous timescale of 30/6/03 not met, this requirement is carried forward. The home must ensure that an assessment to identify the activity needs of residents is completed, this must include their likes and include therapeutic activity. Previous timescale of 30/4/05 not fully met, this requirement is carried forward. The temperature of the refrigerators in the kitchenettes must be maintained at a safe DS0000036766.V265976.R01.S.doc 8 9 OP9 OP11 13(2) 12(1)(2)( 4) 11/11/05 31/01/06 10 OP11 18(1)(c) 31/03/06 11 OP12 16(2)(n)( m) 31/01/06 12 OP15 13(4) 31/12/05 Jubilee Gardens Version 5.0 Page 24 13 OP16 22(3)(4) 14 OP18 13(6) 15 OP22 23(1)(c) 16 OP26 16(2)(k) 17 OP27 12(4)(a) 18(1)(a) 18 OP27 18(1)(a) level. Previous timescale of 31/7/05 not met, this requirement is carried forward. The home must ensure that the complaints log includes whether the complaint was substantiated and if the complaint is resolved. Previous timescale of 30/4/05 not met, this requirement is carried forward. All staff must be trained in how to protect vulnerable adults from abuse. Previous timescale of 31/10/05 not met, this requirement is carried forward. The blue support chair (box type) on Clarence Unit with split seam must be repaired or replaced. Previous timescale of 31/8/05 not met, this requirement is carried forward. The control of strong odours in residents’ rooms must be effectively managed. Previous timescale of 31/7/05 not met, this requirement is carried forward. Staffing rosters must identify the role of staff and the unit they are working on. This must include night staff and when agency staff are employed. Previous timescale of 31/8/05 not met, this requirement is carried forward. The staffing levels on Windsor Unit must be reviewed and take into consideration the care needs of residents. See standard 27 in DS0000036766.V265976.R01.S.doc 31/12/05 31/03/06 31/12/05 31/12/05 31/12/05 31/12/05 Jubilee Gardens Version 5.0 Page 25 19 OP28 18(1)(a) 20 OP30 18(1)(a) the main body of the report. Previous timescale of 31/7/05 not met, this requirement is carried forward. A minimum ratio of 50 of care staff with NVQ 2 in Care or equivalent must be maintained at all times. All staff must have up to date training in safe working practices to include; 1. 2. 3. 4. 5. Basic Food Hygiene Infection Control Manual Handling First Aid Fire Safety and Prevention 31/03/05 31/03/06 All staff must be provided with appropriate training in the work they perform, this must include how to support residents with sensory impairment. Previous timescale of 30/4/05 not met, this requirement is carried forward. The home must ensure that staff and stakeholders are involved in the process of reviewing the homes performance against its statement of purpose and aims and objectives. Previous timescale of 30/9/05 not met, this requirement is carried forward. An annual report of Quality Assurance must be produced, this must be made available to residents and interested parties. All care staff must have supervision six times a year and the supervisor must follow DS0000036766.V265976.R01.S.doc 21 OP33 24 31/03/06 22 OP36 18(2) 31/12/05 Jubilee Gardens Version 5.0 Page 26 through issues raised during the supervisory sessions. Previous timescale of 30/6/05 not met, this requirement is carried forward. All registered nurses must receive adequate support through clinical supervision. Previous timescale of 30/9/05 not met, this requirement is carried forward. All staff must attend fire drills at least twice a year. Previous timescale of 31/1/05 not met, this requirement is carried forward. Fire risk assessments when reviewed must include clear details of the findings and areas of compliance against control measures. 23 OP38 23(4)(d) 31/12/05 24 OP38 23(4) 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP35 Good Practice Recommendations It is recommended that all transactions for managing residents money are witnessed and signed for accordingly. Not assessed at this inspection and is carried forward. Jubilee Gardens DS0000036766.V265976.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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