Inspection on 20/04/05 for Jubilee House

This inspection was carried out on 20th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Jubilee House 13/06/07

Jubilee House 14/08/06

Jubilee House 20/09/05

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 Lesley Garrett Unannounced 20 April 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 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 H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Jubilee House Address Pound Lane, Godalming, Surrey, GU7 1BX 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) 01206 854555 Care UK Community Partnerships Limited Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex, CO4 4YQ Mrs Marjorie Ann Moore Care home with nursing (N) 48 Category(ies) of Dementia - over 65 years of age (DE(E)), 45 registration, with number Mental disorder, excluding learning disability or of places dementia (MD), 3 Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 45 beds providing nursing care for category DE(E) (Dementia - over 65 years) 2 Variation for one (1) named person under the age of 60 with mental disorder, excluding Learning Disability or Dementia. Date of last inspection 21 July 2004 Brief Description of the Service: Jubilee House is a large care home providing nursing for 48 service users with dementia. The home is divided over two units and is situated in a quiet back street in the centre of Godalming town, accessible to the high street amenities by a short walking distance. Care UK Partnerships Ltd, a Corporate organisation is the Registered Provider. All bedrooms have an en-suite facility. The home was purpose built for older persons. A refurbishment programme took place summer 2004. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection by the Commission for Social Care Inspection for the year 2005/2006 and two inspectors attended. The manager was present for this inspection and made us feel very welcome. Staff were also helpful and were willing to talk about the service users in their care and about their duties. Due to the condition of the service users they were unable to make any comments on the home but there was one relative present who said that she could not fault the service. There were four requirements from last inspection and three have now been met. Letter has now been sent to the provider to address the remaining requirement. . What the service does well: What has improved since the last inspection? The home has been decorated and carpeted throughout with new wood flooring in the communal lounges. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 6 There was no offensive odour as the new cleaning product is effective. There continues to be an on going decorating programme but with very little disruption to the service users. The heating system has been upgraded and also the light bulb covers have been replaced both a requirement from the last inspection. 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 House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4,5. People who use this service are told about the home to enable them to make a choice about living there. Family and friends are involved to help service users in their choice of home. EVIDENCE: The Manager or Unit Manager assesses all prospective service users prior to their admission to the home. The files of the recently admitted service users were looked at and all had a pre admission assessment in place. The Manager stated that she speaks to the families and social services prior to admission to assure them their needs can be met. Families or representatives are encouraged to visit the home and assess the suitability of the premises and facilities prior to admission. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 The service users have individualised care plans to meet their needs. The home has good support from visiting practitioners ie. the G.P. and speech therapist EVIDENCE: Individual care plans were seen and there was a good range of documentation for each service user. Daily records are written twice a day and all have risk assessments in place. Due to the service users condition they are unable to sign the care plans and relatives are encouraged to read and sign the individual plans on their behalf. The home has good support from the local G.P. who visits regularly and has good communication with relatives too. The home also has a good relationship and support from speech and language therapist and are then able to adjust their diet according to their needs. The manager did comment that it had not been easy to obtain chiropody or physiotherapy services and private chiropody has to be paid for those who need it. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 The home provides social activities and has some support from the local community. The service users maintain contact with family and friends and their spiritual needs are well catered for. Meals are cooked at the home and looked appetising and nutritious. EVIDENCE: The home employs a full time and part time activities organiser who arrange a variety of leisure interests. The activity organiser said that it did not matter how advanced their disease they could still benefit from social input. She noticed a difference in the service user if there had been no social activity for a couple of days. Family and friends take service users to the local shops in and a local secondary school helps out with the outings. Visits include shopping trips in a mini bus also a day at Wisley gardens which was enjoyed. The local vicar holds a communion service once a month and religious services weekly. The Roman Catholic priest will visit if asked. A hairdresser comes twice a week. The Manager holds a relative group meeting in the home and welcomes their opinions. The Manager explained that all meals were cooked on the premises and the service users were enjoying roast lamb. Some meals had been liquidised to accommodate those service users with swallowing difficulties. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 There is a complaints procedure in place. EVIDENCE: Each service user has the complaints procedure in their room attached to the wall as you enter. This is available for the relatives or carers as service users would be unable to access this information.It can also be found in the service user guide. The complaints procedure is also explained on admission. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,24,26 Service users live in a safe, well maintained environment with access to safe outside grounds. Their bedrooms, where possible , have been personalised with their possessions around them and photographs on the wall. EVIDENCE: The home was clean and tidy and free from any trip hazards. Service users were walking around freely making use of the communal spaces. There is a well maintained garden on the upper floor (the home is built into a hill) which all service users can access in good weather and a patio garden downstairs. It was noted on inspection that the unit manager could unlock the outside door to enable access if the service users wanted to go outside. Service users can walk outside safely and the unit manager explained they often have afternoon tea on the patio in good weather. There are communal lounges which can also used for activities with pictures of recent events on the wall. There is a smoking room where service users can smoke if they want to but under the supervision of a member of staff. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 13 Service users were making their way to lunch in the communal dining room which was bright and comfortable. All bedrooms had a good sized window and were bright and cheerful having been recently decorated. Service users had their personal possessions around them one lady had a large cuddly dog sitting on her bed the Manager explained this was her best friend. There was new carpet in the rooms and along the corridors with no unpleasant odours and the domestic was cleaning. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 There was a mix of registered nurses and carers on duty at the time of inspection. All relevant checks are made prior to employment and the staff have undergone training and some carers are doing level 2 NVQ. EVIDENCE: There was a trained nurse on duty on each floor and carers. The Manager did state that the dependency level had increased and therefore she would be speaking to the provider to increase the staff by one carer on each flor to meet the needs of the service users. The manager and care manager are under going NVQ Level 4 and a number of staff are doing NVQ level 2 and the domestics have completed level 1 NVQ. Recruitment files were inspected. The inspector was concerned that the Manager did not get to see the police checks from the CRB ( criminal records bureau) before employment is confirmed. Checks are sent to head office. CSCI will write to the providers. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Health and Safety policies are in place and staff receive training in all health and safety matters. EVIDENCE: The Manager stated there had been no changes to health and safety issues and they had actioned the last requirement. The heating system had been upgraded and the light bulb covers had now been replaced. Incidents and accidents are always reported to CSCI. Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x 3 Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 17 Are there any outstanding requirements from the last inspection? yes. CSCI will follow up with provider 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 29 Regulation 7,19 & schedule 2 Requirement Registered provider to ensure original CRB checks kept in the home to be reviewed by the inspector. Timescale for action Immediate 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 Good Practice Recommendations Jubilee House H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 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 H58 S17619 Jubilee House V222848 200405 Stage 4.doc Version 1.30 Page 19 - 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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