Inspection on 16/11/05 for Jubilee Gardens

This inspection was carried out on 16th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jubilee Gardens 12/12/06

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 Unannounced Inspection 16th November 2005 09:40 Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 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.V261559.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 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.V261559.R01.S.doc Version 5.0 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 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) South Yorkshire Housing Association 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.V261559.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 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. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 09.40am to 3.30 pm. Most of the service users were seen during the inspection. Six service users, five staff and the manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection? Only one recommendation to redecorate the dining area had not been carried out. However, the manager confirmed that there were plans to carry out this work within the near future. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 6 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.V261559.R01.S.doc Version 5.0 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.V261559.R01.S.doc Version 5.0 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): 2. Service users individual aspirations and needs were assessed prior to their admission, to ensure that the service was able to meet the service users full range of needs. EVIDENCE: A full needs assessment was carried out for all service users prior to their admission. Assessments included the Care Programme Approach and plans of care had been developed based on these. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. Service users confirmed that they had been involved in their assessments. Two service users files checked demonstrated that regular reviews had taken place to reflect the changing needs of the service user and a clear plan of care was in place with the action that was required from staff, to ensure that their individual needs were met. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 9 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): 6,7,8 and 9. Service users had individual plans, which contained detailed information about their care and support needs. Service users were encouraged by staff to make decisions about their present lifestyles and future aspirations through the care planning process. Regular meetings were held with service users to seek their views on how they wished the service to be developed. Risk assessments, which supported service users to lead full lifestyles, minimised risks for the individual had been devised and reviewed regularly. EVIDENCE: Care plans checked set out in detail the action that was required by staff to ensure that all aspects of service users personal, social support and healthcare needs were met. Service users confirmed that their plan of care had been completed with their involvement, ensuring that they were given the opportunity to agree with staff the support that they required to live as independently as possible. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 10 Records checked and discussions with service users confirmed that care plans were reviewed on a frequent basis to reflect their current needs. Service users spoke positively about their ‘keywork sessions’, where the staff supported them to make independent decisions about their lives. One service user commented that due to the support from the staff they had “ enabled me to gain confidence” and spoke positively about “moving on” to live independently. Service user meetings were held regularly, which enabled service users to contribute to the running and organisation of the home. One service user had recently been nominated as a resident representative to listen to service users views to discuss at service user meetings. Service users files contained detailed risk assessments relating to all aspects of service users lives both inside and outside the home. They clearly identified the individual risks that were presented to service users on a daily basis and the action required to reduce the risk, which enabled service users to live an independent lifestyle. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 11 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): 11,12,13,15 and 17. Service users were encouraged to maintain and develop social and independent living skills. Opportunities were provided for service users to engage in activities within the home and maintain links within the local community. Service users were encouraged to eat a healthy and varied diet. EVIDENCE: Service users had regular opportunities to access appropriate activities. Regular activities were available at the core house, which service users said that they enjoyed. The majority of service users were observed to be spending their day as they wished, which included shopping, attending day centres or pursuing personal hobbies. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 12 Service users said that training and educational opportunities were available and that they staff would assist and support them should they wish to undertake further education. One service user had recently commenced voluntary work one day per week, which they were enjoying and felt that it had helped build their confidence. All service users had responsibility for housekeeping tasks, which included cleaning their own bedrooms and personal laundry. Care plans checked incorporated a personal ‘weekly planner’ which gave a clear structure as to how the service user should plan their day and included shopping, washing, cooking and ironing. Staff were able to demonstrate how they encouraged service users to develop social and living skills in preparation for independent living. Service users were encouraged and supported to maintain positive relationships with their families and friends. Service users confirmed that their relatives and friends could visit them at any time. Service users were offered and encouraged to eat a healthy diet. Service users living in the core house were responsible for planning and preparing some of their meals dependent on their abilities and personal aims. One service user who had recently moved into a flat spoke in detail about how the staff had supported them in budgeting and planning meals and how she was now able to shop for food independently. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 13 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. Service users received personal support, which promoted their privacy, dignity and independence. Service users physical and emotional needs were met. Service users were encouraged to retain, administer and control their medication within a risk management framework. EVIDENCE: 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 health teams within the community, for example, community psychiatric nurses had been involved in supporting the staff to meet the service users needs. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 14 A key worker system was in place, which ensured that service users received consistent support from a designated named worker. All service users spoke positively about their designated worker and the support that they had received. It was positive to see two service users who had progressed from the core house and were now living relatively independently in the supported flats. One service user commented, “The staff have helped me, to gain confidence and to be myself”. There was a medication policy and procedure to ensure that staff adhered to safe practices. Service users had been consulted about staff assisting them with medication and risk assessments had been carried out to identify if service users could administer their own medication. Risk assessments in place clearly identified the level of support that service users required to safely administer their medication. The staff confirmed that service users were regularly monitored to check that they were taking their medication appropriately based on their risk assessment. The medication was checked on a sample basis. Records maintained for medication received into the home did not clearly record the amount of stock that had been received and it was difficult to track the specific medication and amount that had been received. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 15 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. The home complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure, which promoted the protection of service users. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Service users stated that they were satisfied with the care provided and that they had no complaints. Service users were confident that any complaints/concerns would be dealt with appropriately. One service user commented that the staff “will listen to any problems that I have”. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. All staff had received Adult Protection training as part of their induction programme. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 16 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): 24,25,26 and 30. The home was clean, comfortable and on the whole well maintained. Service users were provided with an environment that met their individual needs and lifestyles EVIDENCE: The home was generally well maintained and was furnished in a homely manner. All areas seen were clean. Domestic staff were employed to clean communal areas and to ‘deep clean’ service users bedrooms on a monthly basis. The patio area and gardens were well maintained. Service users bedrooms were comfortable, individually furnished and personalised to meet their needs. Standards of cleanliness and hygiene within the main kitchen were good. However, the doors to two of the kitchen units were loose and worn and required repair or replacement to promote a safe environment. One light within the kitchen was out of order and required repairing to ensure that adequate lighting was provided for staff and service users to safely prepare meals. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 17 A routine programme of maintenance and decoration was in place. All areas seen were clean, tidy and generally well maintained. The décor within the main dining areas was showing signs of wear and tear and was in need of redecoration. A sample of service users flats were seen all of which were clean, comfortable and appropriately furnished to promote independent living. The walls in the lounge area of flat 6 were chipped and were in need of redecorating to improve the décor. Service users were responsible for laundering their own clothes and bed linen. The laundry room had appropriate equipment to meet the service users needs. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 18 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): 32,34,35 and 36. Service users were confident that a caring and competent staff team supported them. Staff received training and support appropriate to their role. The home operated a recruitment policy that promoted the protection of service users. The frequency of staff supervision needed increasing to ensure that the staff were given the opportunity to discuss their development and to identify any training requirements. EVIDENCE: All service users spoke positively about the staff team and described them as “supportive”, “Good” and “helpful”. It was evident that staff had formed positive relationships with service users. All service users commented positively about their designated keyworker and described in detail the support that they had received to live independently. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 19 All staff had received training that included Induction and Foundation, Medication, Risk management and First aid. Refresher training was identified and offered to staff on a regular basis, which enabled them to develop their skills and keep up to date with changing legislation. One staff member who had recently been employed at the home confirmed that they had received the appropriate induction and support to carry out her role in a safe manner. A recruitment policy and procedure was in place that promoted the protection of service users. Two staff files checked contained a range of required information including two references, declaration of health and qualifications/training. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level. The manager confirmed that the staff received regular supervision to enable them to discuss their development and to identify any training requirements. However the two staff files checked demonstrated that the staff had not received formal supervision since June 2004. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 20 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. Forums were in place, which enabled service users and staff to contribute to the day-to-day running of the home. The health, safety and welfare of service users was promoted and protected. Records demonstrated that not all staff had received regular Fire drills to ensure that they were fully conversant with the action that they needed to take in the event of a fire. EVIDENCE: Service users spoke highly about the staff team and the service that they received. It was positive to see the progress that service users had achieved since the last inspection. In particular two service users had moved from the core house into the semi-independent flats and both were confident that they would soon be able to live independently within the community. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 21 Service user meetings were held on a regular basis, which provided them with the opportunity to contribute to the day to day running of the service. Service users appeared relaxed and were observed to be following their preferred daily routines. 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 staff had received regular training to promote the health, safety and welfare of service users and their colleagues. Fire systems were checked on a frequent basis. Fire drills were being conducted, however records demonstrated that not all staff had received regular drills to ensure that they were fully conversant with the action that they needed to take in the event of a fire. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Jubilee Gardens Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X 2 X X DS0000018259.V261559.R01.S.doc Version 5.0 Page 23 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 2 3 4 5 6 Standard YA20 YA24 YA24 YA24 YA36 YA42 Regulation 13 23 23 23 18 13,23 Requirement A clear record of medication received must be maintained The light within the kitchen must be repaired. The doors to the identified Kitchen units must be repaired or replaced. The lounge in Flat 6 must be redecorated. Staff must receive regular, recorded Supervision meetings at least six times per year. All staff must receive regular fire drills. Timescale for action 30/12/05 30/12/05 30/12/05 30/12/05 30/12/05 30/12/05 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 YA24 Good Practice Recommendations The dining room should be redecorated within the next six months. Jubilee Gardens DS0000018259.V261559.R01.S.doc Version 5.0 Page 24 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.V261559.R01.S.doc Version 5.0 Page 25 - 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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