Inspection on 18/07/06 for Jubilee Gardens

This inspection was carried out on 18th July 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 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 11/11/05

Jubilee Gardens 15/06/05

Jubilee Gardens 29/12/04

Jubilee Gardens 07/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Jubilee Gardens 26 Wyegate Close Castle Bromwich Birmingham West Midlands B36 0TQ Lead Inspector Sean Devine Key Unannounced Inspection 18th July 2006 09:55 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee Gardens Address 26 Wyegate Close Castle Bromwich Birmingham West Midlands B36 0TQ 0121 730 4560 0121 730 4569 jubilee.gardens@craegmoor.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Craegmoor Healthcare Care Home 50 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (12) of places Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of persons for whom personal care (DE(E)) is provided at any one time shall not exceed 13. The number of persons for whom nursing care (DE(E)) is provided at any one time shall not exceed 25. 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. 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. The number of persons for whom transitional care (OP) is provided at any one time shall not exceed 12, of whom three may be under 65 years of age. The Transitional Unit must be staffed separately to the other units in the home. A minimum of 336 care staff hours (excluding qualified staff) must be provided each week. There must be 24 hour RGN cover at all times. Sensitive and regular reviewing mechanisms must be in place to increase staffing levels when the majority of service users have high dependency needs. Service users admitted to the Transitional Unit must be discreet and clearly distinguished from the other units, and must not at any time be cared for in any of the other units in the home. One named service user under the age of 65 years with dementia may reside at the home. 11th November 2005 4. 5. 6. 7. 8. Date of last inspection Brief Description of the Service: Jubilee Gardens is a purpose built home situated in Smiths Woods in Castle Bromwich. It has extensive secure gardens on a level ground, making access for residents easy, the gardens are beginning to mature. The home has facilities for 50 residents in total, 13 requiring personal care, 25 requiring nursing care and 12 transitional care beds, some of the residents occupying permanent accommodation may 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 Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 5 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 DS0000036766.V298815.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced by two regulation inspectors over a period of two days. Many of the residents do have needs that impact on their ability to communicate, so many of the views and opinions of this home are made by relatives and other information has been made using the inspectors ability to assess signs of well being. The inspectors were able to meet many of the residents and their relatives, who were able to share their views and opinions of the home. Six residents were case tracked, which meant meeting with them and viewing many of their records pertaining to their health and social care. A tour of the premises was undertaken; on this visit inspectors focussed upon communal areas of the home and records of health and safety assessments, practice and contracts were seen. Staff and management records for training, supervision and recruitment were sampled and three staff were informally interviewed. Inspectors observed other management and staff practices. The inspectors were also able to view records about day to day operations in the home such as accident records and how quality is managed. What the service does well: The staff at the home always ensure that residents needs are assessed before they make a decision on whether they can meet the needs of residents. After admission a more detailed assessment of need is completed and care plans are written, which are clear and concise to inform staff on how to meet the needs of residents. One relative stated she was aware of the care plans whilst another relative indicated he had been asked whether he would like to be involved and had declined. Residents are provided with accommodation that enables them to walk about freely without undue risk, relatives are pleased with the standard of cleanliness and confirmed they have been involved in bringing important photographs and memorabilia into residents rooms and that they can have visits in private if they so wish. Staff are available in good numbers to ensure all residents needs can be timely met, it was one relatives opinion that there are always staff available when Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 7 help is needed and another stated “staff are very helpful and will come and help when I ask”. The staff are recruited only after all checks such as Criminal Records Bureau disclosures and references have been made available and any concerns about staff performance are effectively addressed by the new manager. One relative commented that he had seen a lot of the new manager and although happy with the old manager was pleased to see that this manager was also very good. The home does provide an activity therapist, relatives stated that she was quiet new to the job, however records indicated she has started to look at activities that are purposeful and individual to each resident. The manager has responded appropriately to complaints made at the home, this was further supported by relatives who said they would have no reservations about approaching the manager or a member of staff with their concerns. The relatives who met the inspector did not have any cause for complaint. What has improved since the last inspection? What they could do better: Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 8 Following on from the assessments of need in respect of the activities and interests of residents, a care plan needs to be implemented detailing the aims and objectives, how it is to be achieved and who will implement the care plan. Records of all activities must be maintained and the care plan must be subject to regular review. The senior nurses and manager must ensure that staff who help residents with moving do so in a safe and well planned manner. The manager and senior nurses need to ensure that the management of residents medicine on Balmoral Unit is at all times safe. The manager must ensure that the training programme is fully implemented and that as a minimum all staff do attend the arranged mandatory training sessions. Quality assurance must be further developed in the home to ensure that residents and where needed their representatives such as the next of kin are asked their opinions and views on the homes ability to meet its stated purpose and the needs of residents. An annual statement on quality must be available to all interested parties. The proposed arrangements of managing some residents money through a central bank account must have safety mechanisms built in through the risk assessment process and include auditing of the accounts. The manager must ensure that staff are provided with supervision and that it is conducted frequently enough to provide them with adequate support. The manager must ensure that all staff attend fire drills at least six monthly or twice a year in line with homes policy on fire safety. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 6. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home demonstrates its ability to ensure they can meet the needs of prospective residents and that prospective residents are able to make an informed choice on whether to live at the home. EVIDENCE: Six residents were case tracked. The residents on Kensington and Clarence units were found to have contracts on their files detailing the terms and conditions of residency. Some of the contracts were found not to have been signed and it is not fully evident that the residents or their representatives are aware of the terms and conditions. All residents were found to have holistic assessments of need for their activities of daily living. This information had been gathered prior to admission and included an assessment by a nurse from the home and also reports and care plans from social workers. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 11 The home does not provide intermediate care; it does however have a 12bedded unit called Balmoral Unit, which specialises in transitional care with beds contracted to Solihull MBC. This unit does not specialise in Rehabilitation. The unit focuses upon the immediate health needs of residents whilst plans for discharge are being made. Physiotherapy and social worker input is available from the community. The home has a dedicated team of nurses (RGN’s) and care assistants for the unit. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home generally has the capacity to ensure that the personal and healthcare needs of residents are met, yet poor management of medicines does not support this judgement and residents may be put at risk due to poor practice in stock control. EVIDENCE: The sampled residents files across all four units included care plans, these care plans had been developed following a holistic assessment of need. All care plans were found to be clear and concise detailing what staff must do to meet the needs of residents. All files also included risk assessments for moving and handling, nutritional screening, tissue viability and falls. These risk assessments also included management plans, for example the moving and handling risk assessment recorded the task, how many staff and what equipment is needed. During the lunch on Kensington unit staff were observed assisting a resident who on three occasions slipped down the wheelchair, staff initially gave prompts to sit back up, however when this failed staff needed to intervene, it was evident that the resident could support his own weight, to Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 13 ensure safe moving and handling it appeared staff needed to use a support belt, this was not used and staff supported much of the residents weight across their arms and shoulders. The manager was informed that many care plans and risk assessments are available to meet the same need, thus they can be repetitive. The manager was also advised that following assessment if a need is identified then a care plan must be developed or if a risk is identified a risk assessment and management plan must be developed. On Balmoral unit residency is short term, yet care plans are in place for identified needs and management plans to meet these needs; these include personal and nursing care, barrier / isolation nursing and social care needs. Risk assessments are carried out and there is evidence of good practices in wound management. There are also where needed records of fluid and dietary intake and of vital signs such as blood pressure. It was evident that all care plans and risk assessments are frequently evaluated, these evaluations stated whether the care plans were effective or not. The staff write in daily reports using a numbering system to cross reference care plans and risk assessments. Relatives informed the inspector that they are extremely pleased with the standard of care provided at the home and one resident on the Transitional Unit informed the inspector how wonderful the unit was and that she did not want to go home. Residents’ files also contain a record of professional healthcare visitors; these records indicated that residents see their GP when needed and also routine appointments with an optician and a chiropodist. There were no records seen regarding dental care, however a nurse advised that a service is available if needed. All residents on Kensington, Clarence and Windsor units had a care plan to support their oral healthcare requirements. The management of medication was assessed on two units, Balmoral and Kensington; on Kensington unit it was found to be well managed and reflected the newly revised medicines policy. Medication administration records were fully completed including, when medicines were received and when administered to residents. The nurses on Kensington need to ensure that when external preparations such as ointments are opened that the date of opening is recorded. Storage and disposal of medicines on this unit is well managed in line with the policy. There were however concerns on Balmoral unit where many discrepancies were found in the amount of stock of medicine for two of the three residents who were case tracked. All medicines on this unit are supplied from hospital pharmacy, they are all boxed or bottle medicine, where as all other units use a monitored dosage system, which is blister packed. On the first day of the inspection an immediate requirement was issued to the home to ensure that the handling and management of medicines were safe and that poor practice was addressed. On the second day of the inspection the manager advised that this had been discussed with the nursing staff on the unit and actions had commenced to remedy these concerns. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 14 Throughout the two days of inspection staff were observed attending to the needs of residents, this was managed in a respectful and dignified manner at all times ensuring the privacy of residents. Residents files all included care plans to advise staff of how to meet the personal, nursing and healthcare needs of residents. One relative explained that the staff are always very polite and always address residents by their name and that they always knock on doors and respect privacy during visits. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has the capacity to meet the daily life and social activity needs of residents, which enable them to lead a life based upon choice and preference, improvements are needed to introduce more purposeful activity and the staff have the ability to introduce these changes. EVIDENCE: The home has an activity therapist who provides support to residents on all four units. The sampled residents files indicate that the therapist had devised a care plan for residents activities, these were seen to be rather brief and did not always include information recorded about lifestyles in the “Getting to know you” document or within dementia care assessments. The plan for some residents who are frail and who have advanced dementias is to provide one to one activities including the use of touch. No records in activity care plans or daily records were seen to evidence this activity. At the last inspection the home were required to provide training for staff so they have the skills to enable them to communicate effectively with residents who have a sensory impairment, this had not been completed. Since the inspection visit the manager has provided additional information gathered from the new activity Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 16 therapist, which confirmed that the staff on Windsor Unit have organised and held a pub lunch. Future plans include a visiting theatre performing “Aladdin” and arrangements have commenced to hold a summer fete. The inspectors were able to meet with relatives; they had no concerns about privacy when visiting. A form was seen in residents files known as a Relatives Communication form; this included information about the residents such as items needed e.g. toiletries and also about consent for trips out of the home. One relative advised the inspector of regular meetings with the relatives and sometimes residents. Most residents in the home do not have the ability to safely handle their own financial affairs, this is identified as a need for most residents and care plans are in place to provide support, in many cases this role is taken over by family members. There are notice boards about the home informing residents and relatives of external agencies, such as those recorded upon the displayed Complaints Policy. Relatives are able to help with personalising residents’ rooms; they can bring in photographs and personal possessions such as small items of furniture and pictures. The inspectors were able have lunch on Kensington and on Balmoral unit. The menus are cyclical. Copies of the menus were supplied with the pre inspection questionnaire; these menus indicate that a varied and nutritional diet is available with lots of choice including two options for dinner and other alternatives such as baked potatoes and omelettes. The meals served on the units were of good portion and tasty, residents were reminded of the menu and served accordingly. These meals were presented based upon the needs of residents including special diets and food that required blending. On Kensington unit seven of the twelve residents used the dining room, others either used the lounge or ate whilst moving about the unit. Mealtimes are staggered, 12.30 for Windsor and Balmoral and 1.30pm for Kensington and Clarence units, this system appears to work well and provides a minimum of three staff to support residents needs at mealtimes. A food hygiene and food standards inspection was undertaken by Solihull MBC in March 2006; the report was positive and no requirements were made of the home by the environmental health officer, this included an examination of the Hazard Analysis Critical Control Point assessment for food safety. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home demonstrates its ability to implement required policies and procedures in order to enable complaints to be raised and services improved and to protect residents from possible harm. EVIDENCE: The home maintains a log of complaints. Two complaints have been recorded in 2006. The log records details of the complaint, it also states the outcome of an investigation and includes an action plan where needed to improve services. The complaints policy was last revised in 2002 and should be further reviewed to update on current organisations that could be involved in the complaints process. The commission has not received any complaints about Jubilee Gardens in the past twelve months. Relatives informed the inspector that they have no cause for complaint at present yet if they were concerned they would speak to the manager or staff. The home does have a policy on the protection of vulnerable adults, as with complaints it should be revised. However it does reflect local guidelines on good practices and the Department of Health’s document “No Secrets” and provides the staff with a safe procedure to manage concerns about abuse and vulnerability. The current manager has when needed worked in collaboration with other agencies to raise concerns for some residents, this has always been Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 18 completed quickly and with the best interests of residents in mind. She has taken quick and decisive actions to ensure the safety of the residents. The home has a detailed training programme in place and this does include training staff in protecting vulnerable adults, at present 55 of staff at the home have been trained and the manager advised that the programme is ongoing. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 and 26. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has the ability to ensure that the environment is maintained to a good standard and that it meets the individual and group needs of residents. A good range of facilities are available to promote the independence of residents and also for staff to safely support residents when needed. EVIDENCE: It was evident that the home has a schedule of routine refurbishment and redecoration. Since the last inspection some units have had armchairs and specialist seating replaced, new pictures on walls and they have been redecorated. Relatives said they were very happy with the bedrooms and that they had no concerns about communal areas. Most communal areas were seen by the inspectors, including lounges and dining areas. These areas were found to be well maintained and comfortable with good facilities to meet the needs of residents. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 20 All residents’ rooms have an en-suite facility comprising of a toilet and wash hand basin. Each of the four units have communal toilets, shower room and assisted bathroom, close by residents’ rooms. The shower room and bathroom provide appropriate support for residents with mobility and moving needs. Each unit has a sluice room; this is used for managing used laundry and clinical waste. Two residents were seen to need barrier / isolation nursing, staff practice included wearing aprons and gloves and to ensure laundry was managed separately. All high-risk areas such as toilets and sluice areas had good hand washing facilities and where needed a hand disinfectant was available. Some improvements are needed including cleaning the under side of hoist seats and ensuring rubber floor mats are kept clean. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does have the ability to ensure they provide good numbers of staff who are available to support residents in good numbers and who have been safely recruited. The home does have the capacity to ensure improvements in staff training are fully addressed and this will then provide residents with support from staff that are fully skilled and competent in their roles. EVIDENCE: Staffing rosters were provided with the pre-inspection questionnaire, however it was not always possible to identify which staff are allocated to which unit. During the inspection inspectors were provided with some daily allocation sheets, this practice enables the senior nurses and managers to allocate staff to where more support is needed. It was evident that during busy times of the day a minimum of three staff were available on all units. The transitional unit always has a registered general nurse (RGN) in charge, whilst the two nursing dementia units either have a RGN or a registered mental nurse (RMN) in charge. The fourth unit is residential for older adults receiving personal care with a dementia and this unit normally has a senior care assistant in charge. At night there are a minimum of ten staff on duty, allocated to units dependent on levels of support needed by residents, thus providing flexibility and a practical approach. Two of these staff are qualified nurses one of whom is an Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 22 RGN. Relatives commented that there are always staff available to help and that they have no concerns about staffing levels. Training statistics provided by the homes administrator indicated that there are currently 55 of care staff qualified to at least NVQ level 2 in Care. Following a recent recruitment drive including increasing the numbers of staff employed, as bank there has been little need for the home to use agency staff. To assess the practice of recruitment two staff files were sampled, one for a nurse who works on the bank and another for the activity therapist. Both files included all relevant checks; medical screening, criminal records bureau disclosures and POVA and both employees had two written references. An application form had been completed and both members of staff had been interviewed. The staff training summary provided by the administrator indicates that there are some gaps with regard to safe working practice training and also training to meet the specific needs of residents. This included 67 of staff attending fire safety and 68 attending Health and Safety. 50 of the staff had attended Dementia Care training. With regard to the new induction training standards provided by Skills for Care the organisation will have completed the new documents which are currently being printed (work books) prior to the 30th September 2006 when it needs to be fully implemented. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has the capacity and does through good practices and legislation promote the safety of all persons in the home. Some improvements are needed to fully protect residents’ finances and it is within the homes ability to achieve this. EVIDENCE: The manager has clearly made a positive impact in the improvements demonstrated by the home. It is evident that the changes that have been made have improved the quality of the service experienced by residents, for example; the manager has used her experience and skills to develop relationships with nurses and care staff, which has in turn had an impact in care delivery; she has been able to manage challenging events positively such Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 24 as managing staffing issues and improving person centred care planning. The manager advised the inspectors that she intends to commence a programme of dementia care mapping to assess the well / ill being of residents and implement action plans for each unit to continuously improve care practices. The manager has previously managed care services within different capacities including, general manager and senior nurse. An application to register the manager with the commission is needed. The Craegmoor organisation has a quality assurance system, which includes gathering information from audits. It was not evident that residents and their representatives are consulted as part of this process and no report detailing the findings was available to the inspectors. The home does manage some money on behalf of residents. Two residents accounts were sampled, both were found to be fully reconciled. The money available was correct with the balance. Receipts were available where the home had made payment from the account for example to hairdressers and chiropody. The administrator informed the inspector that for some residents a central account was being set up to receive their personal allowances. As yet no risk assessment has been completed to ensure the account is managed safely and include who manages it, how it will be audited and what restrictions there might be for residents to access their money. One relative commented, “when money is needed I’m normally told by the staff” and “staff sometimes tell me what she needs and I bring it in”. Two staff files were sampled and they included evidence of supervision, it was apparent that although their roles and training and development are discussed that supervision is not frequent enough to provide adequate support. The manager advised that she supervises senior nurses, who in turn supervise nurses and it’s a cascading effect to ensure all staff are involved in the process. It was clear that staff who are not permanent and who work on the bank are not supervised as frequent as is needed. The management of safe working practices in the home is good and demonstrates that Health and Safety is taken seriously. Risk assessments for fire, premises and staff have been completed. There is a detailed code of practice for safety in the kitchen. The premises risk assessments have been completed by another organisation that are in the process of providing the home with a report. Fire safety is well managed; all equipment is tested and serviced including regular servicing of the fire system and emergency lights. Many staff do attend fire drills however it was evident that some do not attend as regularly as others. The testing and maintenance of utilities including water, gas and electric is well maintained and other tests and servicing such as passenger lift and nurse call systems are routinely completed. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 25 The manage conducts a monthly audit of accidents in the home, recording time, activity and whereabouts and has analysed the information to determine whether there are any patterns to these accidents. The manager advised this enables her to quickly identify where there is any concern and to take appropriate action. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 2 Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1)(b)(c) Requirement Contracts detailing the terms and conditions of residency must be signed by residents or their representatives. 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. Risk assessments and the associated risk management plan must be completed for immediate risks and care plans completed for ongoing needs. Previous timescale of 31/8/05 not met, this requirement is carried forward. The manager must ensure that staff at all times safely meet the moving and handling needs of residents. Accurate stocks of medicines must be maintained at all times. Previous timescale of 31/12/06 Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 28 Timescale for action 30/09/06 2 OP7 15(1) 30/09/06 3 OP7 13(4) 12(1) 30/09/06 4 OP8 12(1) 13(4) 13(2) 31/07/06 5 OP9 20/07/06 not met, this requirement is carried forward. The manager must ensure the safe handling and administration of medicines in the home with particular attention to the poor practices on Balmoral Unit, this must be addressed and made safe. The manager must ensure that all external preparations including creams and ointments are dated when opened. The home must ensure that an assessment to identify the activity needs of residents is completed, this must include their likes and include therapeutic activity. Previous timescale of 30/4/05 not fully met, this requirement is carried forward. A care plan based upon this assessment must be in place for all residents and staff must record the activities of residents. The manager must ensure that cleanliness is maintained in bathrooms and shower rooms including the underside of chairs used to hoist residents into the bath and also with rubber floor mats. All staff must have up to date training in safe working practices to include; 1. 2. 3. 4. Basic Food Hygiene Infection Control First Aid Fire Safety and Prevention 6 OP9 13(2) 31/07/06 7 OP12 16(2)(n)( m) 31/10/06 8 OP26 23(2)(d) 31/07/06 9 OP30 18(1)(a) 31/10/06 All staff must be provided with appropriate training in the work they perform, this must include Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 29 how to support residents with sensory impairment. Previous timescale of 30/4/05 not met, this requirement is carried forward. 10 OP31 Care Standards Act 2000. 24 The responsible individual must ensure an application is made to register a manager with the commission. The home must ensure that staff and stakeholders are involved in the process of reviewing the homes performance against its statement of purpose and aims and objectives. Previous timescale of 30/9/05 not met, this requirement is carried forward. An annual report of Quality Assurance must be produced, this must be made available to residents and interested parties including the commission. 12 OP35 13(6) 17(2)(9) The central account for managing residents money must have a risk assessment in place to ensure it is safely managed, It must include who has responsibility for managing it, how the account will be audited and any restrictions on residents accessing their personal allowance money. 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 staff must attend fire drills at DS0000036766.V298815.R01.S.doc 31/08/06 11 OP33 31/12/06 31/08/06 13 OP36 18(2) 31/10/06 14 OP38 23(4)(d) 31/12/06 Page 30 Jubilee Gardens Version 5.2 least twice a year. Previous timescale of 31/1/05 not met, this requirement is carried forward. 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 YA40 Good Practice Recommendations It is recommended that policies be reviewed to reflect current information, legislation and guidance on good practices. Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Jubilee Gardens DS0000036766.V298815.R01.S.doc Version 5.2 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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