Inspection on 15/06/05 for Jubilee Gardens

This inspection was carried out on 15th June 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 11/11/05

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 B36 0TQ Lead Inspector Sean Devine Announced 15 June 2005 & 16 June 2005 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 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 E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Jubilee Gardens Address 26 Wyegate Close Castle Bromwich Birmingham B36 0TQ 0121 730 4560 0121 730 4569 Telephone number Fax number Email 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 Vacant Care Home 50 Category(ies) of Older People, Dementia registration, with number of places Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom personal care (DE) is provided at any one time shall not exceed 13. 2. The number of persons for whom nursing care (DE) is provided at any one time shall not exceed 25. 3. 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 4. 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. 5. The number of persons for whom transitional care (OP) is provided at any one time shall not exceed 12. 6. 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. 7. 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. 8. Variation to enable one named service user (RF) under the age of 65 years with dementia to reside at the home. . Date of last inspection 29 December 2004 Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 5 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 have dementia. The home has designated communal and private rooms, all bedrooms have en-suite 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. The home has adequate parking space and is close to the local shopping area and other local amenities. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed over a period of two days on an announced basis; four regulation inspectors were involved in the inspection of this service. Pre-inspection information was provided by the home and comments cards were completed by the residents prior to the inspection. The inspectors were able to meet with many residents and their relatives; staff were interviewed informally and records in respect of care provided and health and safety practices in the home were seen A full tour of the home was undertaken. The home is currently without a manager. What the service does well: What has improved since the last inspection? Staff were seen to communicate well with the residents and to be patient and respectful when assisting residents with their meals and care needs. Written care plans to inform staff on how to meet the oral health care needs of residents have been developed. Daily records of the care and events in the lives of residents are more informative. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 7 The home has notified the commission of any accident or incident in the home that has affected the well being of residents. The dining areas at mealtimes are pleasant and fully equipped to meet the needs of residents. Carpets have been cleaned and are now well maintained. The home has reviewed the staffing levels on the transitional care unit to meet the needs of the residents. 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 E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 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 standard(s) 1,3,4,5 and 6 The home provides prospective residents and their representatives with relevant information about the home, this enables them to make a decision as to the suitability of the home. The home completes assessments and gathers pre-admission information; this enables the home to ensure that they can meet the needs of prospective residents. EVIDENCE: The home has developed a Statement of Purpose that fully describes the facilities and services available in the nursing, residential and transitional units at the home. The home provides a service users / residents guide to the home; these were seen in the majority of residents rooms. A range of pre-admission information was available this included social services care plans, the homes pre-admission assessment known as “Dementia Care Evaluation” and life histories of residents completed by family members. The home has a range of facilities and services including aids and adaptations, special menus and has trained staff to specifically meet residents needs in Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 10 some areas. However it is clear that the home has not maintained clinical supervision of nurses, some areas of the service are not reflective of current good practice e.g. life histories of residents do not impact on written care plans. One resident informed the inspector that an invitation to visit the home was made prior to admission, however this was declined and family members and social workers advised as to the homes suitability. The home does not provide service for intermediate care. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 and 11. The home does not assess and plan the care of residents to a level that is safe and that will meet all the needs of residents. Care staff are not fully instructed in how to meet the needs of residents. Healthcare provision including medication practice is poor and puts some residents at risk. EVIDENCE: The standards of care planning were found to vary across the different units of the home. Written care plans on the transitional unit were found to be inadequate for some residents in that some were not specific, e.g. residents using hoists and slings did not have recorded the type of hoist or the type of sling needed. Risk assessments on this unit identified the risk but did not detail how staff will provide measures to reduce the risk. Waterlow’ pressure area assessments were in place as were nutritional and manual handling assessments but findings from assessments had not been consistently acted upon. The residential unit has detailed assessments of needs, risk assessments and care plans. All activities of living had these completed. All risk assessments Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 12 and their related management plans had been repeated in the written care plans. Risk assessments for nutrition, manual handling and Waterlow had been completed. Some risk assessments did not identify specific concern and others were not individual and did not include the residents name. Activities of daily living were also in place and were found to be in part informative, they identified what the residents needs were but did not record what the abilities of the resident are. Written care plans and some risk assessments did not always specifically include what staff do to assist. The nursing units also had detailed activity daily living assessments, risk assessments and written care plans. On this unit the risk assessments also repeated the care plans. Risk assessments had been be completed for ongoing daily living activities when there was no identified immediate risk. Daily records, reviews of assessments and care plans should be used to identify any risks. Life histories for some residents had been completed, these documents also include the biography, history and pastimes of the residents, and it was unclear in care plans how these needs were to be met. Some assessments had not been fully completed, some had no dates, some had not been signed; some had been completed by ticking boxes failing to fully identify need or risk. Some risk management plans need further information to detail how supervision or support is to be given. Records are maintained when residents see the GP and other healthcare professionals. No records pertaining to seeing a dentist were available on four residents files. Two files contained no information in respect of chiropody. The needs of residents with pressure sores had been planned for, however these plans specified an overlay mattress; on checking the mattress it was found to be a cellular mattress. The care plans must specify the specific mattress residents are using in their rehabilitation. Standards of medication practice vary in the home. The transitional unit uses medicines that residents receive when discharged from hospital, they are then temporary registered with the homes GP, medicines are then supplied in boxes and bottles. The medication administration charts (MAR) did not include photos of residents. Practice on the unit was seen to be mainly safe. The fridge temperatures need to be taken and recorded on a daily basis. The nursing units and the residential unit mainly use a blister pack system provided by a local chemist. The units had copies of the doctors ‘prescriptions, which they use to confirm the correct receipt of the residents medicines, two MAR had not recorded all medicines received into the home. Stock control was generally found to be good however one controlled drug no longer required had not been returned to pharmacy. Medicine practice on Kensington unit was of concern, many copies of GP prescriptions were not available, some medicines had not been administered with no recorded reasons and stocks of medicines were inaccurate when Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 13 counted. Some prescribed medicines that should have been in use were found to be unopened in the medicine fridge. The area manager was left an immediate requirement to audit and correct poor medicine practice. Staff do receive information about promoting privacy, confidentiality and respect of residents in their induction training. Staff were observed to address residents in their preferred manner and were sensitive to maintaining the residents dignity and self esteem when assisting with all personal care. All residents have their own rooms with en-suite toilet facilities. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 The daily living and social activity needs of residents are not met by the home, some practices are in need of improvement to ensure that residents’ needs are fully met in an individual and safe way. At mealtimes residents are not adequately supported by staff and cannot be sure they will receive meals at times convenient to them and commensurate with their needs. EVIDENCE: The lifestyles of residents are not fully assessed at the home, not all residents have a life story completed and the social and recreational needs in the activity of daily living assessment are not fully informative. Relatives confirmed that there was no regular activity schedule, only the television which at times would be tuned into children’s programmes. Relatives were able to visit the residents at reasonable times, all visits were seen to take place in communal areas. Some relatives disclosed that they were at times concerned that the home did not always contact them on behalf of the residents should the need arise. The staff and relatives informed inspectors that the relatives would mainly manage money on behalf of the residents; further information is recorded in Standard 35 of this report. Residents do have a choice on whether to bring in decoration and small items of furniture into their rooms this includes personal valued possessions. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 15 Mealtimes offer a nutritional meal to the residents, this includes cooked breakfasts, optional lunches and dinners and regularly available snacks and special diets. Dining areas were well presented with table cloths and place settings. The lunchtime meal was seen to be distressing for some residents, increasing their agitation levels. It was clear that there was not enough staff on the nursing units to feed residents or to encourage and provide minor assistance when required. Some residents required full assistance with their meals and were seated in the lounge, it was noted one member of staff was left in the dining room who was serving residents, encouraging some to eat and assisting other residents. The meals on one nursing unit were not served until almost 2pm and the lunch meal finished at 3.20pm. This being to close a period to tea-time which is identified on the pre-inspection questionnaire as served between 4.30pm and 5.30pm. The pre-inspection questionnaire identifies lunch as being served between 12.30 and 1.30pm. It was clear staff who came on duty at 2pm went without a detailed handover, they immediately went to assist residents with their lunch. The inspectors noted that the posture of some residents was not appropriate for eating meals, some residents who use wheelchairs were not sitting in a supported fashion that is as upright as the individual resident could be, and safe. The main kitchen was noted to be clean and hygienically maintained. Most food items were stored correctly either in a fridge or a freezer. Fresh fruit and vegetables are available and so are dry food items such as biscuits, crisps and chocolates. The cook must ensure that all food items in the freezer are labelled appropriately. Each unit has its own kitchenette annexed from the dining area, essential food stocks including milk and bread must be available in these unit kitchens when the main kitchen is closed at 7pm. The temperatures of the refrigerators in these areas must be maintained at a safe level. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18. Systems and procedures are in place to allow residents and their representatives the freedom of civil rights, including voting, raising and advocating areas of concern. Staff training on adult protection is needed to fully afford protection for the residents. EVIDENCE: Complaints received by the home over the last year have been fully detailed in the complaints log, however actions and whether complaints have been upheld or not have not been recorded. The home has a complaints policy that is on view and is included within the residents’ guide, it requires updating to include the current Director of Care Services. Some records were seen on the residential unit that indicate that residents are able to make postal votes and take part in the civic process The home has with guidance from the CSCI needed to refer on two occasions in 2005 to the local authority to implement POVA procedures. The home has its own procedures that reflect good practice. Some staff have received training in protecting vulnerable adults from abuse. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 17 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 standard(s) All standards. The home provides well furnished and generally well maintained communal areas for residents, residents rooms are individualised and provide residents with adequate facilities to meet their needs. EVIDENCE: The home has a maintenance person who has a scheduled weekly and monthly plan of work, records are routinely kept of completion of this scheduled work. The grounds of the home were throughout found to be clean and tidy. The home is unitised (four units) with each unit having its own communal areas which include dining area, large lounge, seating by staff / nursing stations and quiet / visiting rooms. All furnishings and furniture in communal areas are of a good standard. Both ground floor units down stairs have direct access to a garden, the garden areas are shared with the upstairs units. All garden areas are of a design that will allow wheelchair access. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 18 All residents’ rooms include en-suite toilet and each unit has a range of toilet, bathing and showering facilities. In some shower rooms the shower curtain needs replacing and attention must be given to the very noisy extraction fan units in some shower and bathrooms which besides affecting communication between staff and residents does not promote a relaxing bathing or showering experience. The home has a range of aids and adaptations to provide support for the residents including grab rails, hoists, slings, emergency call, specialised mattresses and specialised seats. The blue support (box type) chair on Clarence unit has split in part at the seams and needs repair. Other aids available include bed rails and rail bumpers, the home has not established consent to use these rails or discussed the risks with residents and their representatives. All rooms are for single occupancy and provide adequate space for residents. They are furnished with a range of furniture this is provided as standard in all rooms and includes divan bed, table, chest of drawers, single wardrobe and a bedside cabinet. Some residents have small items of their own furniture such as bookshelves. All rooms are carpeted and have suited locks. A range of lighting is available in residents rooms including over bed, bedside and ceiling lights, emergency lighting is provided throughout. The home throughout is centrally heated and all radiators have covers. All hot water supplies to showers and baths are thermostatically controlled and of good pressure. Water tanks are regularly chlorinated and water temperatures tested and recorded for all hot and cold supplies. Infection control practice is generally good, the laundry area and clinical waste are effectively managed and infection control procedures are put into practice such as colour coded cleaning. Improvements are needed to adequately control strong odours in certain areas such as two residents’ rooms. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30. The numbers of staff on duty and at shift handovers does not meet the ongoing needs of residents. Staff generally have the skills to meet the current needs of the residents, and good recruitment practice in the home means that residents are protected in the home.. EVIDENCE: The home has four units; The Balmoral (transitional) (up to 12 residents) nursing unit is staffed with one registered nurse and three care assistants during the day. Kensington and Clarence (nursing, 13 and 12 residents respectfully), dementia care units are staffed with one registered nurse, usually a Registered Mental Nurse and two care assistants during the day on each unit. Windsor Residential unit (13 residents) is staffed with one senior care assistant and one care assistant. Night cover includes a minimum of two trained nurses, (being a minimum of one Registered General Nurse) and a minimum of seven care assistants. It is not clear from the staff rosters on which unit nursing staff are based and where agency care and nursing staff are based. The role of staff is not always clear on the staff roster. Staffing levels at meal times on the dementia care nursing units as identified in standard 15 are not adequate and they must be revised to meet the needs of Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 20 residents. Staffing levels on Windsor Residential unit are at times inadequate due to the social care needs of residents which should include external to the home activities such as shopping and leisure and at times some residents need a minimum of two staff to safely manage their care needs. Informative and confidential staff handovers must take place but this should not be during the residents’ lunchtime. Staff were observed handing personal information about residents over to each other whilst supporting residents with their lunch. The home has a robust recruitment process that includes pre-employment checks such as Criminal Records Bureau disclosures and written references. The administrator maintains a detailed training matrix; this includes safe working practice training such as manual handling, fire safety and infection control. It was evident from the matrix that some staff needed refresher training and that other staff needed to undertake training. Some staff have completed additional training such as continence awareness, bereavement care and general medicine management. It was evident from sampled staff files that some staff had received training in understanding dementia. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,36,37 and 38. The home is without a manager and effective leader to ensure that residents are empowered, policies and procedures implemented and that informed decisions are taken. The lack of adequate support to monitor staff performance and development of needs considered does not ensure that the home is run in the best interests of residents. EVIDENCE: At the time of inspection the general manager position was vacant, the area manager has confirmed that the post has been offered to an experienced manager subject to required checks. The home has senior nurses in charge on a day-to-day basis; the area manager is also using the home as a base for some days of the week to provide additional support. On the days of inspection the administrator assisted with the co-ordination of the inspection, however it was evident that Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 22 there was no clear leadership and decision-making based upon good planning and with the aims and purpose of the home in mind. The home does provide a facility for residents to have their money and valuables kept in safekeeping. Accounts, including receipts of transactions were available and the balances were all found to be correct. It is recommended that all transactions are witnessed and signed for accordingly. Sampled residents files also included inventory of belongings completed on admission. Staff are receiving supervision, the care staff are receiving supervision from nurses and previously nurses were receiving some general supervision from the previous manager. It was evident from the supervision records that these sessions are not frequent enough to adequately support all staff. Nursing staff have not been receiving supervision that will help maintain and develop their clinical practice. Policies that reflect current practice were sampled these included equal opportunities, confidentiality, missing persons, philosophy of care which includes equality, accidents and adult protection. They were seen to reflect good practice and were informative for staff. The records pertaining to health and safety were seen, these include the testing, servicing and maintenance of fire systems, electric, gas, water, passenger lift, hoists and call systems. All were seen to be upto date. The home has in place extensive staff, building and premises risk assessments. The fire risk assessment needs to include the findings from the assessments and have the compliance section completed as part of its review. The inspector was concerned that some fire drill records indicated a poor response from staff and that appropriate actions to improve this had not been undertaken or had not been recorded. The fire drill records are extensive and drills are undertaken regularly, however it is not clear that all staff attend drills twice a year or that evacuations are practiced, no evacuation plans were seen. The garden area had a hard plastic pond liner with a large amount of water in it and the garden gazebo was held in place by ropes, the pond and ropes are potentially hazardous for residents and staff. Residents’ daily records and information disclosed by relatives indicate that some residents are receiving minor injuries such as bruising to forearm, no analysis of when or how these minor injuries have been sustained was available. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 1 COMPLAINTS AND PROTECTION 3 3 2 2 3 3 3 2 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 2 1 x x x 3 2 3 2 Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 24 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 OP2 Regulation 5(1)(b)(c) Requirement All service users contracts detailing terms and conditions of residency must be signed by the service users or on their behalf by the nearest relative or an advocate. Standard not assessed at this inspection, this requirement is carried forward. The assessment of need including the life histories of residents must be used to develop written care plans. 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. Written care plans must be Timescale for action 31/8/05 2. OP3 14(1) 30/9/05 3. OP7 15(1) 31/10/05 4. OP7 15(1) 30/9/05 5. OP7 15(1) 31/8/05 Page 25 Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 6. OP7 13(4) completed which include specific details such as type of hoist and sling used in manual handling and where a risk is indicated such as on a Waterlow risk assessment. Risk assessments and the associated risk management plan must be completed for immediate risks and care plans completed for ongoing needs. Risk assessments must always be fully completed including dates and signatures, the risk must be clearly identified. The plans to manage risk must include actions / measures to be taken in order to reduce the risk not one word entries such as supervision and socialising. All residents must have recorded access and treatment of a chiropodist and an optician. 31/8/05 7. OP8 13(1)(b) 31/8/05 8. OP8 15(1) 9. OP9 13(2) 10. OP9 13(2) Previous timescale of 30/4/05 not met, this requirement is carried forward. Special equipment used in the 31/8/05 treatment of pressure sores e.g. cellular matresses must be correctly recorded in written care plans. The transitional unit must have 24/6/05 photos of residents on the medication administration record (MAR). Refrigerators used for the 31/7/05 storage of medicines must have the temperature recorded daily. The home must ensure that all medicines received into the home are recorded on the MAR. Previous timescale of 31/04/05 not met, this requirement is 31/7/05 Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 26 carried forward. All controlled drugs must be disposed of in accordance with the medicine policy. A medicines audit identifying poor practice and risks to residents including a count of tablets must be undertaken and corrective actions taken. The home must have evidence of the prescribing wishes for all medicines administered to residents, e.g. a copy of the GP prescription. Previous timescale of 30/4/05 not met, this requirement is carried forward. 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. . 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 has not been met. 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 Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 27 31/7/05 18/6/05 31/7/05 11. OP11 12(1)(2)( 4) 31/8/05 12. OP11 18(1)(c) 30/11/05 13. OP12 16(2)(m)( n) 30/9/05 not fully met, this requirement is carried forward. A programme of activity must be implemented to reflect the 30/9/05 assessed needs of residents. 16(2)(m) The home where needed by the 31/8/05 resident must contact the next of kin and inform them of any relevant changes related to their well being. 18(1)(a) The home must provide 31/7/05 16(2)(i) additional staff to support 13(4)(b)(c residents with their meals at ) lunchtime. The practice of residents having a lunch time meal within 2 hours of their evening meal must be reviewed and actions to address taken. Residents must be supported and encouraged to sit in a safe position for eating. The home must ensure that all food items in the freezer are labelled appropriately. The temperature of the refrigerators in the kitchenettes must be maintained at a safe level. Essential food items must be available in the unit kitchenettes when the main kitchen is closed. 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. The complaints policy on display Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 28 14. OP13 15. OP15 OP27 31/7/05 31/7/05 31/7/05 31/7/05 31/7/05 31/8/05 16. OP16 22(3)(4) 17. 18. OP18 OP21 13(6) 23(1)(c ) must be updated and include the current Director of Care Services. All staff must be trained in how to protect vulnerable adults from abuse. Shower curtains where missing must be replaced. Noisy extraction fans in shower and bathrooms must repaired. The blue support chair (box type) on Clarence Unit with split seam must be repaired or replaced. The use of bedrails and bumpers and the associated risks must be discussed with residents or their representatives. Consent to use them needs to be given and recorded with the risk assessment. The control of strong odours in two residents rooms must be effectively managed. Staffing rosters must identify the role of staff and the unit they are working on. This should include night staff and when agency staff are employed. The staffing levels on Windsor Unit must be reviewed and take into consideration the care needs of residents. See standard 27 in the main body of the report. Staff must not handover information whilst assisting residents with their lunch time meal Handovers must take place within an area of the home that does not compromise confidentiality of information being shared. All staff must have upto date training in safe working practices to include; 31/8/05 31/10/05 31/7/05 19. OP22 23(1)(c ) 31/8/05 20. OP22 13(4)(c ) 31/8/05 21. 22. OP26 OP27 16(2)(k) 17(2) schedule 4 (6)(7) 18(1)(a) 31/7/05 31/8/05 23. OP27 31/7/05 24. OP27 12(4)(a) 18(1)(a) 31/7/05 25. OP30 18(1)(a) 31/10/05 Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 29 1. 2. 3. 4. 5. Basic Food Hygiene Infection Control Manual Handling First Aid Fire Safety and Prevention All staff must be provided with appropriate training in the work they perform, this must include how to support residents with sensory impairment and how to support residents at mealtimes. Previous timescale of 30/4/05 not met, this requirement is carried forward. The registered provider must recruit a competent, appropriately experienced and suitable qualified manager. The registered provider must make interim arrangements for the home to be effectively managed. Details of interim arrangements must be forwarded to the CSCI. 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. Standard and requirement not assessed at this inspection. This requirement is carried forward. All care staff must have supervision six times a year and the supervisor must follow through issues raised during the supervisory sessions. Previous timescale of 30/6/05 not met, this requirement is carried forward. All registered nurses must Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 30 26. OP31 8(1)(a) 9(1)(2) 31/10/05 27. OP31 10(1) 31/7/05 28. OP33 24 30/9/05 29. OP36 18(2) 30/9/05 30. OP38 23(4) 31. OP38 23(4)(d) receive adequate support through clinical supervision. The fire risk assessment must include the findings from the assessments and have the compliance section completed as part of its review. All staff must complete annual fire safety and fire drill training twice a year. The manager must ensure that all staff respond appropriately to the fire alarm. Previous timscale of 31/1/05 not met, this requirement is carried forward. The garden area must be made safe for residents; The hard plastic pond liner must be removed. 31/8/05 17/6/05 32. OP38 13(4)(a) 16/6/05 33. OP38 13(4) 17(1)(a) schedule 3 (3)(j). The ropes attaching the gazebo to the ground must not present a 15/7/05 tripping hazard. An analysis of small injuries on 30/6/05 all units must be undertaken on a monthly basis 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. Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 31 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Jubilee Gardens E54 S36766 Jubilee Gardens V184752 150605 Stage 4.doc Version 1.30 Page 32 - 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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