Inspection on 12/12/06 for Jubilee Gardens

This inspection was carried out on 12th December 2006.

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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jubilee Gardens 16/11/05

Jubilee Gardens 07/07/05

Jubilee Gardens 22/03/05

Jubilee Gardens 01/10/04

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

CARE HOME ADULTS 18-65 Jubilee Gardens 18 Jubilee Gardens Royston Barnsley South Yorkshire S71 4FL Lead Inspector Jayne Barnett-Middleton Key Unannounced Inspection 12th December 2006 11:00 Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 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 DS0000018259.V303491.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 Adults 18-65. 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 DS0000018259.V303491.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee Gardens Address 18 Jubilee Gardens Royston Barnsley South Yorkshire S71 4FL 01226 701980 01226 701981 g.thompson@syha.co.uk None South Yorkshire Housing Association 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) Mrs Gina Thompson Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: Jubilee Gardens is a purpose built property for service users with mental health needs. The home provides intermediate care with the intention that service users will progress to independent living. There is a core unit and six semiindependent flats on site. The core unit is on two floors, serviced by a passenger lift and comprises of ten single bedrooms with en-suite facilities, two lounges, a dining room, kitchen, laundry room and offices. Car parking is available at the front and there are lawned gardens to the rear. The project is on the edge of a housing estate in Royston, where there are good community facilities. It is on the bus route from Wakefield to Barnsley. The fees for the care offered at the home at 12/12/06 are £297 per week. The homes statement of purpose, service user guide and complaints procedure is available in appropriate formats. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection conducted by Jayne Barnett-Middleton. Prior to the visit contacts made to The Commission For Social Care Inspection, the homes service history and a pre-inspection questionnaire were examined. Six service user questionnaires were returned. A fieldwork visit took place from 11am until 18.30pm. Opportunity was taken to tour the premises including four of the six flats and inspect a sample of records including care plans and staff recruitment files. The inspector spoke in detail to the deputy manager, five of the staff on duty about their knowledge, skills and experiences of working at the home and to six service users about their views on aspects of living at the home. The inspector wishes to thank the deputy manager, staff and service users for their assistance and time throughout the inspection process. What the service does well: What has improved since the last inspection? All previous requirements had been met. Since the last visit the kitchen units had been replaced and new light fittings had been fitted to a good standard. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 6 The staff spoken to confirmed that they were receiving supervision on a regular basis. The deputy manager was in the process of conducting staff appraisals to discuss their development and to identify any training requirements. Fire drills were being conducted, and records demonstrated that staff had received regular drills, to ensure that they were conversant with the action that they needed to take in the event of a fire. 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 DS0000018259.V303491.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Information about the service and what support the service user could expect to receive was available. However, service users would benefit from being reminded of the homes service users guide, its purpose and how it can be accessed. Service users support needs and aspirations were assessed prior to their admission and their individual needs were reflected in their plan of care. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 9 EVIDENCE: Three service users, via the survey, said that they had received enough information about the home prior to their admission. Three service users said that they had not. Comments included ‘ I did not know about rules and regulations, ‘ I don’t feel I was told enough before I came’ and ‘ I didn’t know about paying rent’ .The deputy manager confirmed that an information pack detailing the homes aims and objectives and what support the service user could expect to receive was in place. Service users were given this information prior to their admission and the deputy manager said that the service users keyworker would also confirm with the service user that they understood the information soon after their admission. Regular service user meetings do take place and there are service user information boards within the home, where the information could be made available. It is recommended that service users be reminded of the homes service users guide, its purpose and how it can be accessed. Three care files seen contained a full needs assessment which had been carried out carried out prior to the service users admission. Assessments included the Care Programme Approach and plans of care had been developed based on these. The homes project workers reviewed the service users support needs regularly, with the service user, to discuss their progress and future goals. Six service users, via the survey, said that they had involved in making the decision to move into the home. Prospective service users were invited to visit the home prior to their admission. One service user, who had recently moved into the home, said that they had stayed at the home for a few days and that this has helped them in deciding that it was the right placement for them. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Service users had individual care plans, which contained specific information about their care and support needs, enabling staff to provide the appropriate level of support. Daily records did require more detail to ensure that the support needs of the service user could be fully monitored. Service users were encouraged by staff to make independent decisions about their present lifestyles and future aspirations through the care planning process. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care files were seen, which described the service users individual support needs. The format was detailed including the service users healthcare needs, emotional control and the level of support that they required to develop independent living skills. The care plans checked had been reviewed on a regular basis with the involvement of the service user. One care review, whilst detailed, did not state who had carried out the review or if the service user had been involved to agree their support needs. Daily records of the support offered and wellbeing of the service user were maintained. However, these did require more detail. For example one care record seen acknowledged that the service user had returned from a healthcare appointment with new medication and that the amount to be administered did need clarifying before administering. The medication administration record seen did evidence that this had been carried out. However there was no record in the records seen to detail the action that had been taken and the advice that had been given. Service users were encouraged to make decisions about their lives and were encouraged to live as independently as possible. Five service users, via the survey, said that they could decide what they wanted to do each day, during the evening and at the weekend. The staff said that the routines within the home were flexible and that service users, where able to, were encouraged to spend their day as they wished. Care plans checked incorporated a personal ‘weekly planner’ which gave a clear structure as to how the service user should plan their day which included shopping, washing, cooking and ironing. Risk assessments had been developed for service users, which identified the individual risks that were presented to service users on a daily basis including accessing the community, smoking and mediation. The assessments seen were detailed and practical measures to reduce any presented risks were in place, enabling service users to live an independent lifestyle Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, 16 and 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Service users were encouraged and supported to maintain and develop their social and independent living skills. Good opportunities were available for service users to engage in activities within the home and maintain links with the local community. Service users were satisfied with the meals provided at the home. Where needed, the staff to supported service users to plan and cook their meals independently. EVIDENCE: The manager, via the pre-inspection questionnaire, said that the main focus of Jubilee Gardens was to support and encourage service users to access community resources and facilities. Service users spoken to said that the they did enjoy a wide range of activities including visiting local amenities, attending day centres, playing snooker and going out for meals. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 13 During the visit service users were observed to be spending their day as they wished. Several service users had gone out for the day whilst others had gone out in the morning and were spending the afternoon at home .Two service users said that they planned to go out that evening to a Karate class. Activities within the home were also available. One service user said that they had recently enjoyed an art class that had taken place in the core house. Service users were encouraged to maintain positive relationships with their relatives and friends. One service user said that the stayed with their relatives at the weekend whilst another was looking forward to going home for Christmas. Service users in the core house were encouraged to plan and prepare some of their meals. Project workers supported service users to do this. A cook was employed and a choice of menu was offered for the teatime meal for service users who were not independently cooking their meal. The service users informed the staff on the day of their intention to have a meal. A good choice of menu was offered. The cook said that individual requests would also be catered for. The teatime meal served during the visit looked appetising and was well presented. Service users spoken to said that they were satisfied with the meals provided commenting, “ they are good, there is a good choice” and “ the cook will prepare what I like”. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Service users received personal support, which promoted their privacy, dignity and independence. Healthcare records require improvement to ensure that the health and welfare of the service users can be fully promoted. Service users were encouraged to retain, administer and control their medication within a risk management framework. Some practices do require improvement to fully promote the safety and welfare of the service users. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 15 EVIDENCE: Information provided with the pre-inspection questionnaire demonstrated that service users had good access to healthcare professionals including general practitioners and community health teams. Service users said that their healthcare needs were met and confirmed that the staff encouraged them to take responsibility to make their own healthcare appointments. Care plans checked demonstrated that healthcare professionals, for example community psychiatric nurses and psychiatrist were involved in supporting the staff to meet the service users needs. The care plans seen did not detail the healthcare appointments that the service users had attended although there was a format in place for this. For example one care file contained a letter from a healthcare professional stating that they had seen the service user, and that a follow up appointment to review their medication was planned for two weeks time. When the medication was checked this had occurred. There was however no detail in the service users care plan to detail that they had attended the appointment, the advice give and any follow up support that the staff may need to provide. Medication was checked on a sample basis. Service users had been involved in agreeing the support that they required to manage their own medication. The Medication Administration Records (MAR) seen detailed the medication that the service user was prescribed and staff had signed to confirm that the medication had been administered. There was no record on three MAR records checked of the amount of medication that had been received into the home or who had checked the medication in. One MAR record seen demonstrated that the service user had been without one prescribed medication for a period of three days. The deputy manager explained that this had been due to the service user attending a healthcare appointment on the Friday and returning with no medication. The deputy manager said that the staff was unable to obtain a prescription until the following Monday morning when the healthcare professional was available. However, procedures should be in place to ensure that service users receive their required medication. In some instances staff were handwriting on MAR records. A recommendation was made to ensure that where handwritten entries of medication are needed that two staff check and sign to confirm that the dosage and administration of medication recorded is correct. Medicines, including controlled drugs, were securely stored and procedures were in place to demonstrate that controlled drugs had been administered correctly. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. There is a complaints procedure in place. However, Service users would benefit from being reminded of the processes that are available should they have any concerns about the service that they receive. The homes adult protection policies and procedure promoted the protection of residents from harm or abuse. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 17 EVIDENCE: Since the last inspection no complaints have been to the Commission For Social Care Inspection. Records of any complaints, the action taken and outcome were maintained. One complaint made by a service user had been dealt with by the manager. Six service users questionnaires were returned. Three said that they did not know how to make a complaint. Three service users said that they did. One service user commented that ‘ I don’t know who to write to’ another commented ‘ I would like to be reminded’. Five of the six service users confirmed that they did know who to talk to if they were unhappy. Five service users spoken to during the visit said that they did not know how to make a complaint. One said that they were not sure. Service user meetings are held frequently and a service user involvement coordinator from South Yorkshire Housing Association visits the home on a regular basis, as do the Quality Assurance Officers. There is a complaints procedure in place, which does meet the required standard. However, this needs to be displayed and service users reminded of how to make a complaint, who will deal with their concerns, and who to contact if they are not happy with the outcome. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. Since the last visit three incidents have been dealt with under adult protection procedures. The registered manager has dealt with these appropriately and the commission for social care inspection informed. Staff had received Adult Protection training as part of their induction programme. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home was comfortable and generally well maintained. Standards of cleanliness in some areas did require improvement to fully promote a hygienic environment. EVIDENCE: The home was generally well maintained and the communal areas furnished in a homely manner. Since the last visit requirements in relation to the environment had been met. The kitchen units had been replaced and new light fittings had been fitted to a good standard. Service users do have en-suite facilities in their bedrooms. When the premises, in the core house, were checked a bathroom and toilet on the top corridor were locked and not accessible to service users. The deputy manager said that these had been locked, as there had been in-sufficient domestic staff to maintain the areas to a good standard. The areas, when opened, were clean and made accessible to service users during the visit. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 19 In the main service users were supported by the staff to take responsibility for cleaning their own bedroom or flat as part of their care programme to develop their independent living skills. Domestic staff was employed to clean communal areas and to support service users to ‘deep clean’ their bedroom and flat on a regular basis, dependent on the support that they needed. The communal areas and kitchen within the core house were clean and maintained to a good standard. However, the carpet on the upstairs corridor was in need of a deep clean as it was stained. Two bedrooms seen were in need of a general clean as the carpets were stained the beds unmade and the environment generally unkempt. It is acknowledged that service users should be encouraged to live as independently as possible and that their choice of living should be respected. However, in the inspectors’, opinion the standards of cleanliness seen were not as good as observed on previous visits to the home. Six service users, via the survey, said that the home was always clean and fresh. Four of the six flats were seen. All of which, in general, were clean and well maintained. The lounge carpet in flat 10 was in need of replacement or a ‘deep clean’ as it was stained and appeared unclean. Service users living in the flats said that they were well supported by the staff to clean their home on a regular basis. The deputy manager said that there had been problems in maintaining standards of cleanliness due to a domestic vacancy. However, a new worker had recently commenced employment at the home. The deputy manager said that the domestic staff were in the process of deep cleaning the home. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The home is providing the required number of staff to meet the service users individual needs, although some service users felt that they needed more support than the staff were able to offer. Good training and development opportunities are available for staff, providing them with the appropriate training to meet the service users general and specific needs. In general the homes recruitment procedures promoted the protection of the service users. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 21 EVIDENCE: Three weeks rotas were checked which demonstrated that the minimum staffing levels were being met, to meet the general and specific needs of the service users. Six service user questionnaires were received. Three service users said that they were treated well and that the staff listened to what they said. Three said that they were usually treated well commenting “ I sometimes feel that the staff do not have enough time for me” and “ There needs to be more participation and involvement from the staff”. In general service users spoken to during the visit said that the staff were ‘ helpful’ and ‘supportive’. Two service users living in the flats said that they would like to see more of the staff. One service user living in the core house said that they did need more support. Two of the three care staff spoken to felt that there was enough staff provided. One said that, in their opinion, they didn’t always have the time to offer the support that the service users required. Since the last visit there has been some changes to the staff team and the staff team have worked to ensure that service users have been provided with a consistent level of support. The deputy manager confirmed that a project worker vacancy had been recruited to and that they were due to commence working at the home subject to satisfactory recruitment checks. Training records submitted with the pre-inspection questionnaire demonstrated that the staff team did receive a good range of training, which included first aid, diversity and managing difficult situations. One member of staff who had recently commenced employment at the home confirmed that were receiving good support and guidance during their initial weeks of employment. This included fire and safety procedures and working with an experienced member of staff, until they were confident to work independently. The staff spoken to said that they were receiving supervision on a regular basis. The deputy manager said that she was in the process of conducting staff appraisals to discuss their development and to identify any training requirements. Two staff files were checked, one of which was for a member of staff who had recently commenced employment at the home. The files seen contained a range of information including two references, declaration of health and identification. One file seen did not include the employees’ full employment history. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. The file seen for a member of staff recently recruited evidenced that a POVA 1st check had been carried out prior to them commencing employment. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Good forums were in place, which enabled service users to contribute to the day-to-day running of the home and suggest ideas for improvement. The homes policies and procedures promoted the health, safety and welfare of service users and staff. EVIDENCE: The registered manager will soon be resigning post at the project, as she has recently been successful in gaining another post within the organisation. The manager is currently covering two projects until her position is recruited to. At the time of the visit the deputy manager was generally responsible for the dayto-day management of the home, with the support of the registered manager. In general the staff spoken to said that they felt supported by the deputy manager commenting “ she will always give you her time”. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 23 Meetings were held on a regular basis enabling service users to discuss the service and to suggest ideas for improvement. In addition to this a service user involvement coordinator from South Yorkshire Housing Association visits the home on a regular basis. The deputy manager said that recently service users had requested that their meetings were held in the evening, as it would be easier for them to attend. The night care workers had agreed to facilitate these and were being supported by the service users involvement coordinator in planning and chairing the meetings. South Yorkshires Housing Associations quality assurance officers visited the home on a regular basis to carry out monitoring of the service to ensure that the home was working within the law and their policies and procedures. The quality assurance team, via a recent newsletter, had invited service users to be involved in the quality assurance process by visiting other homes within the organisation to talk to other service users about what was good at the home and what could be done better. Information provided prior to the visit demonstrated that all major systems and equipment, including fire equipment, had been routinely serviced to promote a safe environment. Areas seen during the inspection appeared safe and in general accessible to residents. Fire drills were being conducted, and records demonstrated that staff had received regular drills to ensure that they were conversant with the action that they needed to take in the event of a fire. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 3 X Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Care plan reviews must detail who had carried out the review and if the service user had been involved to agree their support needs. Daily records must detail the action that had been taken and the advice that had been given. Records of healthcare appointments must be maintained. A sufficient stock of medication must be available. Records of medication received into the home must be maintained. Service users must be informed of how to make a complaint, who will deal with their concerns, and who to contact if they are not happy with the outcome. Service users facilities must be accessible. The premises must be kept clean and hygienic. Service users must be supported to maintain a good level of cleanliness. The Carpet in flat 10 must be cleaned or replaced. DS0000018259.V303491.R01.S.doc Timescale for action 01/03/07 2 YA6 17 01/03/07 3 4 5 6 YA19 YA20 YA20 YA22 13,17 13 13,17 22 01/03/07 31/01/07 01/03/07 01/03/07 7 8 YA24 YA30 23 23 01/03/07 01/03/07 9 YA30 23 01/03/07 Jubilee Gardens Version 5.2 Page 26 10 YA34 19 Staff files must contain details of the employees full employment history 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA1 YA20 YA33 Good Practice Recommendations Service users should be reminded of the homes service users guide, its purpose and how it can be accessed. Two staff should witness handwritten entries on medication administration records. Staffing levels should be reviewed to ensure that service users are receiving the appropriate level of support that they need. Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Jubilee Gardens DS0000018259.V303491.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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