Inspection on 07/07/05 for Jubilee Gardens

This inspection was carried out on 7th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Jubilee Gardens 12/12/06

Jubilee Gardens 16/11/05

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 S71 4FL Lead Inspector Jayne Barnett-Middleton Unannounced 7 July 2005 09:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Jubilee Gardens Address 18 Jubilee Gardens Royston Barnsley S71 4FL 01226 701980 None None South Yorkshire Housing Association 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) Mrs Gina Thompson PC - Care Home only 16 Category(ies) of MD - Mental Disorder (16) registration, with number of places Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 March 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 semi-independent 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 J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.00am to 3.00pm. The inspection focused on checking that previous requirements had been met and to seek the views of service users, in relation to the care and personal support that they received. Six service users, five staff and the registered 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 welcoming the inspector into their home. What the service does well: What has improved since the last inspection? The manager was able to evidence that all previous requirements and recommendations had been met. She positively acknowledged that the issues identified at the last inspection had highlighted the need for staff to work more closely together, in particular the need to provide a consistent level of care to service users when their designated named member of staff (keyworker) was not working. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 6 One service user’s file checked, demonstrated that regular reviews had taken place to reflect their changing needs and a clear plan of care was in place with the action that was required from staff. The home’s adult protection policy and procedures had been updated to include Barnsley Metropolitan Council procedures and relevant contact numbers had been incorporated. Staff were scheduled to attend refresher Adult Protection training, to keep them up to date with changing legislation. Appropriate action had been taken to reduce the risk of service users scalding themselves whilst carrying hot drinks from the kitchen to the sitting areas. The manager was able to evidence that she had consulted with Health and Safety advisors, risk assessments were in place and safety information alerting service users to the potential risks, were posted in appropriate formats. Standards of cleanliness and hygiene within the main kitchen had improved since the last inspection. The storeroom and kitchen equipment were clean. Food was stored appropriately and a stock control system was in place. The supplies contract had been reviewed to minimise the amount of cleaning products available and COSHH assessments were in place. Cleaning products were securely stored, which promoted safe working practices. Fire training, to ensure that staff were aware of the procedure and action to take in the event of a fire, had taken place. 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 J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 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 standard(s) 2, 3, 4 and 5. Service users’ individual aspirations and needs were assessed prior to their admission. Prospective service users were offered trial visits to ensure that the service could meet their assessed needs. Service users were issued with a written contract at the point of admission. 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. One service user’s file 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. There was an admission policy to ensure that prospective service users were able to visit the home before making a decision to move there. The manager confirmed that introductory visits were offered over a period of seven days. A minimum three-month ‘settling in’ period was offered to service users, followed by a review, which gave the service user the opportunity to agree with staff the help that they needed to live as independently as possible. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 9 Service users had been issued with a contract outlining the terms and conditions of living at the home. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. Service users’ individual needs were assessed and their changing needs were reflected in their plan of care. Service users were offered the opportunity to contribute to the quality of service that they received. 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. The care plans had been completed with the involvement of the service user, which gave them the opportunity to agree with staff the help that they needed to live as independently as possible. One service user’s plan checked had been reviewed and updated on a regular basis to reflect the service user’s current needs. Service users spoke positively about their ‘keywork sessions’, where the staff supported them to make independent decisions about their lives. Service users described the sessions as “useful” and “they have helped me live independently”. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 11 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. Service user meetings were held regularly, which enabled service users to contribute to the running and organisation of the home. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 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: The routines within the home were flexible. Service users were observed to be following their preferred routines. Several service users had chosen to spend their day at the home socialising with other service users whilst others had planned outings. All service users had responsibility for housekeeping tasks, which included cleaning their own bedrooms and personal laundry. Service users said that this arrangement worked well and that “the staff helped” to encourage them to maintain a clean environment. 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 and ironing. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 13 Service users were encouraged to lead a fulfilling lifestyle. All spoke positively about the organised day trips that they had attended which included Chatsworth House and Scarborough. Service users confirmed, “We go out a lot”. Opportunities were provided for service users to pursue personal interests and recreational activities. Service users confirmed that they enjoyed swimming and fishing. Two service users said that they often visited places within the local community including shops and pubs. Service users were encouraged and supported to maintain positive relationships with their families and friends. Service users confirmed that their relatives were invited to visit them and “I can invite friends for lunch”. Service users were offered and encouraged to eat a healthy diet. One service user who had recently moved into a flat spoke in detail about how the staff had supported them in planning meals and how she was now able to shop for food independently. One service user said that as part of their care plan, they had started to plan, prepare and cook their meals one day per week. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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, “the staff encourage me to make my own appointments”. One service user described in detail their plan of care and how the staff had encouraged and supported to them to maintain their personal hygiene. 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 said that due to the support they had received they “had come a long way”, to live independently. There was a medication policy and procedure to ensure that staff adhered to safe practices. Staff had received medication training; all promoting that medication was appropriately administered to residents. 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. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 15 The manager confirmed that service users were regularly monitored to check that they were taking their medication appropriately based on their risk assessment. One service user confirmed that they were responsible for taking their own medication and that the staff “check my medication twice per week”. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home’s 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 and described the manager and staff as, “approachable”. One service user said, “It doesn’t matter what it is, the staff will always help”. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. A previous requirement to obtain a copy of the Barnsley Metropolitan Council procedures and to provide relevant contact numbers on the home’s adult protection procedure had been met. The manager confirmed that all staff received Adult Protection training as part of their induction programme. Staff were scheduled to attend refresher training, to keep them up to date with changing legislation. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 17 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 standard(s) 24 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 well maintained and was furnished in a homely manner. Service users said that they were comfortable at the home and confirmed “I like it here”. A new rehab kitchen had recently been installed. Service users were observed to be utilising the kitchen, making drinks and snacks. A previous requirement to reduce the risk of service users scalding themselves whilst carrying hot drinks from the kitchen to the sitting areas had been met. The manager was able to evidence that she had: consulted with Health and Safety advisors; risk assessments were in place; and safety information alerting service users to the potential risks, were posted in appropriate formats. Standards of cleanliness and hygiene within the main kitchen had improved since the last inspection. The storeroom and kitchen equipment was clean. Food was stored appropriately and a stock control system was in place. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 18 Staff confirmed that there was a cleaning programme in place to maintain a clean and hygienic environment. Domestic staff were employed to clean communal areas and to ‘deep clean’ service users’ bedrooms on a monthly basis. 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. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35. 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. EVIDENCE: All service users spoke positively about the support that they received and described the manager and staff as “approachable”, “Good” and “helpful”. All staff had received training that included Induction and Foundation, Medication, Risk management and First aid. Refresher training was identified during supervision, and offered to staff on a regular basis, which enabled them to develop their skills and keep up to date with changing legislation. Regular team meetings and working groups took place on a regular basis, which enabled staff to contribute to the development of the service and to review policies and procedures. The manager said that she had considered a previous recommendation to increase the frequency of supervision and staff meetings but believed that appropriate forums were in place to promote good teamwork. The manager did positively acknowledge that the issues identified at the last inspection had highlighted the need for staff to work more closely together and that this had been addressed. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 20 A recruitment policy and procedure was in place that promoted the protection of service users. One staff file 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. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 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. EVIDENCE: Service users spoke positively about the service that they received and described the management team as “Good” and “Approachable”. 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 including day trips, menus and any equipment that they needed. Service users appeared relaxed and there was an informal and friendly atmosphere within the home. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 22 A previous requirement to maintain cleaning products in a safe manner had been met. The supplies contract had been reviewed to minimise the amount of cleaning products available and COSHH assessments were in place. Cleaning products were securely stored, which promoted safe working practices. The staff had received regular training to promote the health, safety and welfare of service users and their colleagues. The manager confirmed that staff had received refresher fire training, to ensure that staff were aware of the procedure and action to take in the event of a fire. Jubilee Gardens J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 23 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 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Jubilee Gardens Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x J51 18259 Jubilee Gardens V235321 07.07.05 UI Stage 4.doc Version 1.40 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation None Requirement Timescale for action 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. 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