Inspection on 14/08/06 for Jubilee House

This inspection was carried out on 14th August 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 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 House 13/06/07

Jubilee House 20/09/05

Jubilee House 20/04/05

Jubilee House 21/07/04

Jubilee House 27/04/04

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

CARE HOMES FOR OLDER PEOPLE Jubilee House Pound Lane Godalming Surrey GU7 1BX Lead Inspector Sandra Holland Unannounced Inspection 14th August 2006 10:45 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 House DS0000017619.V302226.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 House DS0000017619.V302226.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee House Address Pound Lane Godalming Surrey GU7 1BX 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) 01483 420400 manager.burroughs@careuk.com Care UK Community Partnerships Limited Mrs Marjorie Ann Moore Care Home 48 Category(ies) of Dementia - over 65 years of age (45), Mental registration, with number disorder, excluding learning disability or of places dementia (3) Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may accommodate one (1) named person over 65 years of age with a mental disorder, excluding Learning Disability or Dementia. 20th September 2005 Date of last inspection Brief Description of the Service: Jubilee House is a large care home providing nursing for 48 service users with dementia. Care UK Partnerships Ltd, a Corporate organisation is the Registered Provider. The home is divided into two units, one on each floor, both of which have access to enclosed gardens. The home is situated in a quiet road in the centre of Godalming town, with the high street shops and amenities immediately accessible. All bedrooms have an en-suite facility and was purpose built for older persons. A refurbishment programme took place summer 2004. The fees at this service range from £ 656.34 to £ 950.00. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced “key” inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year April 2006 to June 2007, and was carried out under the CSCI Inspecting for Better Lives programme. As the inspection was unannounced, no-one at the home knew it was to take place. Mrs Sandra Holland, Lead Inspector carried out the inspection over eight hours. Mr Nigel Jopson, Manager was present representing the service. Ms Deborah Christian, Responsible Individual for Care UK Community Partnerships was present for part of the inspection. A full tour of the premises was carried out and a number of records and documents were examined, including care plans, medication administration record (MAR) charts, staff files and resident finance records. Twelve residents were met or spoken with and two visitors and thirteen staff were spoken with. A pre-inspection questionnaire was supplied to the home and this was completed and returned to CSCI within the requested timescale. Some of the information from the questionnaire will be referred to in this report. As a group, the people living at the home are referred to as residents and that is the term that will be used throughout this report. Some of the residents at the home have communication difficulties, so their responses were assessed by their facial expressions and body language. The inspector wishes to thank the residents and staff for their hospitality ,time and assistance. What the service does well: Visitors spoke of the kindness of staff and the welcome they receive when they visit the home. Residents’ healthcare needs are well met. A well balanced and appetising choice of meals are provided and these are served in attractive dining rooms. Residents are encouraged to be as independent as possible and are supported to make their own choices. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 6 The home is attractively presented and decorated. It is freshly aired and staff must be given credit for this achievement, given the high dependency levels of most of the residents. Residents’ needs are met by an effective staff team and a number of staff have been recruited to the team since the last inspection. What has improved since the last inspection? What they could do better: Contracts or statements of the terms and conditions of residence at the home must be supplied to residents and these must state the full fees, who is paying the fees or any part of them and how the fees are paid. Assessment of the needs of residents must be carried out before they are admitted and must be fully completed, signed and dated. Care plans must be drawn up for all residents to guide staff to the care and support required. Assessments of risks to residents must include information as to how the risks can be minimised. The receipt of medication into the home must include a record of the quantities received and the amount of medication held must accurately match the record held. Gaps in the medication record must not occur. The social and leisure activities provided and the hours worked by activities staff must be reviewed to ensure that they are sufficient to meet the needs of the residents. All the required records and documents must be obtained before a person is permitted to work in the home, including a full employment history and two written references. Residents’ monies held for safekeeping must not be held in the home’s bank account. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 7 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 House DS0000017619.V302226.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some, but not all residents have been provided with contracts or statements of the terms and conditions of living at the home. The needs of residents are assessed before they move into the home, but some of the assessments have not been fully completed or dated. EVIDENCE: From the records seen, it was evident that not all of the residents have been provided with a contract detailing the terms and conditions for living at the home. It was noted that the home’s contracts did not specify the starting date of the period to be covered. For one resident, the contract held did not specify the fee to be charged, who was to pay or how and had not been signed by a representative of the home. The manager advised that a number of residents are financially supported by local authorities. It was noted that for these residents, a copy of the terms and conditions of the agreement between the home and the appropriate local authority, were not held, as is required. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 10 The files of four recently admitted residents were seen and a pre-admission needs assessment had been carried out for each. One of these had not been fully completed or dated, so it is not possible to know when it was carried out. It is required that all areas are completed and dated. It is recommended that those parts of the assessment that do not apply should be marked as not applicable, to indicate that those areas have been considered and were not overlooked. For one resident, who is supported financially by a local authority, the assessment had been carried out under the care management process. A copy of the assessment had been obtained was held in the home. The manager stated that intermediate care is not provided. Requirements have been made regarding Standards 2 and 3. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most care plans are detailed & effectively guide staff to the needs of the residents, but a care plan needs to be drawn up for one recently admitted resident. Residents’ healthcare needs are well met and residents are treated with respect. The administration of medication must be managed more robustly. EVIDENCE: The manager advised that the home is planning to introduce a computerbased, paperless care plan system and two computers have been provided on each of the units to enable staff to have access. Staff have received training to use the new system. The inspector raised the concern with the manager that care plans must be drawn up, made available and reviewed in consultation with residents or their representatives, and the practicalities of this if a paperless system was to be used. As mentioned previously, the individual files for four recently admitted residents were seen. These included the care plans and assessments of any risks to residents. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 12 The care plans are used to inform and guide staff to the care and support needs of each resident. For most of the residents, the information in their care plan was detailed, complete and had been regularly reviewed. It was pleasing to note that the night care plan had been completed with detailed information regarding the preferred sleep pattern and any other preferences for night-time support. It was noted that for one resident, no care plan had been drawn up, although the resident had been admitted ten days previously. Staff would therefore have difficulty in knowing what care was required for this resident. Where risks to residents have been identified these have been assessed and recorded and guidance is provided to staff in the associated area of the care plan, as to measures that could minimise the identified risks. From the records seen it was clear a number of healthcare professionals are involved in the support of residents, including general practitioners (GP’s), opticians and a chiropodist and that residents’ healthcare needs are well met. Staff stated that medication supplies are provided in different formats for the two units. For one unit, medication is supplied in “blister” packs from a national pharmacy and for the other unit, medication is supplied in original packs and bottles from a local hospital. The receipt of medications is recorded on medication audit sheets. It is of concern that when the stocks of medication held in the home for two residents were checked with the records held, these did not accurately match. The manager explained that this was because medication had been carried forward from previous supplies, but this was not recorded. It was therefore not possible to know at any given time how much medication should be present, or to follow an audit trail. The manager immediately drew up a memo to all staff responsible for the receipt of medication, to address this shortfall. A small number of gaps in the recording of medication that had been administered were also noted and the manager advised that he would address this with the member of staff concerned. Staff were observed to treat residents with respect, offering them choices and encouraging them to make these as independently as possible. Personal care was provided discreetly and in a manner that promoted residents’ privacy. An immediate requirement was made regarding Standard 9 and another requirement has been made regarding Standard 7. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Social and leisure activities need to be given a higher priority to ensure that residents’ social and occupational needs are met. Residents are supported to maintain contact with their families and friends and to be part of the community if they are able. A well-balanced diet is made available to residents. EVIDENCE: An activities programme was supplied with the pre-inspection questionnaire which indicated that activities with the activities co-ordinator were planned for four days each week, and “activities with carers” listed for three days each week. The activities in the programme included cooking, music and movement, bingo, art and crafts, ball and card games and hair and nail sessions. The manager stated that the home currently had only one activities coordinator. He advised that the Care UK organisation are trying a new system of “activity based care” in some of their homes. A brochure explaining this type of care was available in the home’s entrance hall, although the deputy manager stated that she was not aware of this new initiative. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 14 An allocated room for activities has been provided on each of the units, but it was disappointing that neither of these appeared to be in use on the day of inspection. The manager advised that the ground floor activity room had recently been reorganised as a music room and it was pleasing to see small musical instruments were displayed on the walls. A keyboard and music centre were available, but as pictures awaited hanging, the room did not appear to be ready for use by residents. The first floor activity room contained spare items of furniture and an overhead projector, and had recently been used for staff training the deputy manager advised. Due to the level of dependency and high needs of the residents living at the home, few are able to undertake any activities of daily living without assistance. Only a few residents are able to entertain themselves and at the time of the inspection, no meaningful social or occupational activities were observed to be taking place. Three residents were sitting in lounge at the far end of the unit, with no company or stimulation to occupy them. Another resident was sitting in an area overlooking the garden and was keen to go into the garden when the inspector and deputy manager went out there. Other residents were seen in their rooms, but most residents were not being occupied in any way. It is essential that meeting social and leisure needs are given a higher priority, with sufficient staffing hours provided to ensure these needs can be met and the current arrangements and staffing must be reviewed. Relatives of residents were spoken with and they were very positive about the welcome they receive in the home. Staff advised that most residents are not able to maintain telephone or written contact with their families and friends, but are pleased to see their families when they visit. The activity programme incorporates a weekly visit to the local shops for those residents who are able. The deputy manager advised that a day trip to the seaside and a garden party were planned and these were included on a list of activities displayed in the entrance hall. A two-week menu was supplied with the pre-inspection questionnaire and this was seen to be well-balanced and wholesome. Two main courses are offered each day, including a vegetarian meal. The lunch-time meal was seen on the day of inspection. It looked appetising and residents spoken to said they enjoyed their meals. The meal was served in the dining room on each unit, with tables attractively laid with table-clothes, napkins and fruit drinks. Residents were observed to be encouraged to be independent, but staff were on hand to assist any resident requiring help. The meal was available in other forms, such as pureed, for those residents requiring it. Staff advised that residents were able to indicate their choices and those who were not able to communicate easily, would push away their meal if it was not wanted. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 15 A requirement has been made regarding Standard 12. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy is available to all who may need it. Most staff are aware of their responsibilities in the protection of residents, but a number of staff require training in this. EVIDENCE: The home’s complaints policy was openly available and displayed in the main entrance hall, although the pre-inspection questionnaire recorded that no complaints had been received during the last year. Visitors spoken to said that although they were not aware of the home’s policy they would speak to the manager or person in charge in the event of any dissatisfaction. The home would follow the Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults in the event of any incident of abuse, or suspicion of abuse of residents, the manager stated. An up to date copy of this policy is kept on each unit and is available to staff. It was noted that a number of ancilliary and care staff had not received training in the protection of vulnerable adults. This will be referred to at Standard 30 which refers to staff training. Staff spoken to stated that they would report any concerns to the manager or the person in charge and would have no hesitation in doing so. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 17 Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 18 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): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, is suited to its stated purpose and presents as a comfortable place to live. Hygiene in the home is appropriately and effectively managed. EVIDENCE: The home is purpose built and the building is designed in a circular shape, which enables residents to walk a circuit of each unit. Bathrooms and bedrooms with en-suite toilet facilities are situated around the main corridor, with a combined dining room and kitchenette in the centre. Lounges and activity rooms are situated off the main corridor and residents have access to areas of the garden from each unit. To maintain the safety of the residents, access to the premises is by an entry phone system at the front entrance and entry to each unit is safeguarded by an electronic keypad system. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 19 The home is situated in a small close to the rear of the main shopping street in Godalming, although few of the residents are able to access the shops and facilities unaided, staff advised. From the information supplied in the pre-inspection questionnaire, it is clear that an on-going programme of improvements is being carried out. This recorded that the bedrooms on the first floor and all the bathrooms, have been decorated since the last inspection. Further decoration of the ground floor bedrooms and upgrading of lighting is being continued. The deputy manager advised that new curtains had recently been obtained for residents’ bedrooms and that co-ordinating bedspreads and lampshades were awaited, to complete the refurbishment of the rooms. Residents were consulted about the colour schemes of their rooms wherever possible, the deputy stated. All areas of the home were tidy and well presented and it was pleasing to note that the home was freshly aired and odour free, for which staff must be congratulated. The majority of the residents at the home have some difficulties with their continence but this is not apparent. The home appeared clean and hygienic with hand-washing facilities provided in all appropriate places and these were equipped with liquid soap and paper towels. Staff were seen to wash their hands before handling food and to wear personal protective equipment, including gloves and aprons. A well-equipped laundry is situated on the lower ground floor and this is fitted with the appropriate washing and drying machines. The member of laundry staff was spoken with and was aware of the necessary measures to prevent the spread of infection. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A team of staff are employed to meet the needs of residents, most of whom have received the required training. The recruitment of staff needs to be managed more robustly to fully safeguard residents. EVIDENCE: It was clear from the information supplied in the pre-inspection questionnaire, that a full team of staff are employed to meet the needs of residents. Although nursing and care staff make up the majority of the team, kitchen staff, housekeeping and laundry staff, a maintenance worker, an administrator and an activity co-ordinator are also employed. The pre-inspection questionnaire also recorded that a number of care staff, (twenty percent of the total), have undertaken a National Vocational Qualification (NVQ) in care to level 2 or above. As this is under the level of fifty percent of care staff with this qualification specified by the National Minimum Standards (NMS), it is recommended that further care staff undertake this training. A number of staff files were examined and it was clear that the recruitment of staff must be more effectively managed to ensure residents are safeguarded. For two members of staff, only one reference had been obtained, although two are required, and for one of these staff, no record of their induction was Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 21 available. It was noted that a full employment history had not been obtained for three members of staff. It is recommended that the application form that is used in the home is reviewed and revised, as it requests applicants to supply their work history for the past seven years. This does not meet the requirements of The Care Homes Regulations 2001 (As Amended), which specify that a full employment history, together with a satisfactory written explanation of any gaps in employment, must be obtained. It was noted that the staff group is culturally and racially diverse, although the level of diversity is not reflected in the resident group. A staff training record was also supplied with the pre-inspection questionnaire. This confirmed that staff have received a range of training, some required by law, including first aid, food hygiene and fire safety, and other training to develop their knowledge and skills, such as dementia awareness, infection control and managing challenging behaviour. It was noted that a number of staff, including some who have worked at the home for two years or more have not undertaken training in the protection of vulnerable adults. The manager stated that he and the deputy manager had recently undertaken training to enable them to train staff in the home and would shortly be training staff in safeguarding adults. Requirements have been made regarding Standards 29 and 30 and a recommendations have been made regarding Standards 28 and 29. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager’s application for registration with CSCI must be completed and the procedure for managing residents’ cheques must be reviewed. Health and safety in the home is appropriately managed. EVIDENCE: The manager stated that he is a qualified nurse, was appointed to his role in February 2006 and has submitted an application to CSCI for registration. The manager advised that he has appropriate experience, as he has managed two care homes previously, one as a registered manager. The administrator stated that residents’ monies are held for safekeeping as residents are unable to manage their own finances due to the level of their dementia. Most residents are supported in the management of their affairs by their families or representatives. A record is maintained of all deposits, Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 23 withdrawals and expenditure. The records of resident finances were checked with the amounts held and these accurately matched. The process of cashing cheques for residents involves depositing residents’ monies in the homes’ account until it is cleared for cashing, the administrator advised. It is required that this process is reviewed and revised because residents’ monies must not be held in the homes’ account. The details of a number of records and checks relating to health and safety matters were recorded in the pre-inspection questionnaire. This indicated that equipment and systems are checked and maintained to the required frequency. Contractors were present in the home on the day of the inspection, maintaining and checking gas appliances. Health and safety records relating to food storage and cooking were seen and these were recorded appropriately, to the required frequency and within the specified ranges. Requirements have been made regarding Standards 31 and 35. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 2 x x 3 Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Requirement A contract, or a statement of the terms and conditions for living at the home, must be supplied to all residents, which must state the full fees, who is paying the fees or any part of them and how the fees are paid. Pre-admission assessments of the needs of service users must be fully completed, signed and dated by the person carrying out the assessment. The assessments must be carried out by suitably qualified or suitably trained persons. Service users’ care plans must be drawn up for all residents and be fully completed with the required information. Complete and accurate records must be kept of all medication administered to service users to enable an audit trail to be followed. The stock of medication held must accurately match the record held and gaps must not occur in the recording of medication administered. The provision of activities in the DS0000017619.V302226.R01.S.doc Timescale for action 08/09/06 2 OP3 14 14/08/06 3 OP7 15 08/09/06 4 OP9 13 14/08/06 5 OP12 16 10/11/06 Page 26 Jubilee House Version 5.2 6 OP27 18 7 OP18 OP29 18 8 OP30 19 9 10 OP31 OP35 9 20 home must be reviewed to ensure they meet the needs of service users. The number of hours to be worked by activities staff must be reviewed to ensure they are sufficient to meet the needs of service users. Staff must receive training appropriate to the work they are to perform. Specifically, all staff must receive training in the protection of vulnerable adults. A person must not be employed to work at the care home unless the information and documents specified in Schedule 2 have been obtained in respect of that person. Specifically a full employment history and two written references must be obtained. The manager’s application for registration must be completed. Residents’ monies held for safekeeping must not be held in a bank account unless (a) the account is in the name of the resident or any of the residents to whom the money belongs, or (b) the account is not used in connection with the carrying on or management of the home. 10/11/06 10/11/06 14/08/06 30/09/06 10/11/06 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 OP28 Good Practice Recommendations It is recommended as good practice that further staff should receive NVQ training to Level 2 or above, to achieve the target of 50 of trained staff. DS0000017619.V302226.R01.S.doc Version 5.2 Page 27 Jubilee House 2 OP29 It is recommended that the staff application form in use is reviewed and revised to ensure applicants are requested to provide a full employment history. Jubilee House DS0000017619.V302226.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 House DS0000017619.V302226.R01.S.doc Version 5.2 Page 29 - 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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