Inspection on 20/09/05 for Jubilee House

This inspection was carried out on 20th September 2005.

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 14/08/06

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 Lesley Garrett Announced 20 September 2005 10:00 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 H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Jubilee House Address Jubilee House Pound Lane Godalming Surrey GU7 1BX 01206 854555 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) Care UK Community Partnerships Limited Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex, CO4 4YQ Mrs Marjorie Ann Moore Care Home (CRH) 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 H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 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. Date of last inspection 20 April 2005 Brief Description of the Service: Jubilee House is a large purpose built care home providing nursing for fortyeight older persons with dementia. The home is divided over two units on two floors and is situated in a quiete 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. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over four and a half hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Lesley Garrett, Lead Inspector for the service, carried out the inspection. Ann Moore Registered Manager represented the establishment. A full tour of the premises took place. The inspector saw most of the residents and spoke with two in more depth. Due to their mental frailty it was not possible to speak with more. The inspector also spoke with a number of staff. A pre-inspection questionnaire and a number of comment cards were also used to write this report. This was a positive inspection. The inspector would like to thank the residents, staff and manager at Jubilee House for their time, assistance and hospitality during this inspection. Service users will be referred to as residents throughout this report as that is their familiar title. What the service does well: The staff was warm and friendly and talked with ease to the inspector. Documentation was of a good standard with care plans and risk assessments in place and evidence of regular reviews. The administrator has also worked hard with all administration files well managed and has introduced a new system to record and check on CRB’s and the registered nurses PIN. All food is cooked on the premises and the chef told the inspector that they have a high number of residents requiring pureed food but the presentation of this was of a good standard. One visitor commented on the high standard of the food served at the home with the chef very accommodating trying to please the residents. The domestic staff work hard keeping the home clean and tidy and one told the inspector that it was very hard work but that he enjoyed it. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 6 What has improved since 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 H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 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 H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 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) 1 The homes Statement of Purpose and Service user Guide are good providing families with details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: Due to their mental frailty most of the residents have not made a choice about moving to the home this has to be taken by the relatives or their representatives. The home has a comprehensive service user guide and this is available in every bedroom. These guides are written in plain English making them easy to read and understand and are updated on a regular basis. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 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) 9 & 10 The medication at this home is well managed and personal care is offered in a way that promotes and protects resident’s privacy and dignity. EVIDENCE: The system for administration of medication is the monitored dose system using blister packs. Policies and procedures are in place and the two registered nurses the inspector spoke with had a good understanding of best practice. The inspector saw no gaps on the MAR sheets and drug temperatures are taken daily and recorded. There were no controlled drugs on the first floor and the cupboards did not contain excess stock. The manager explained to the inspector the system for their returns of medication. She has now had the bins delivered with a special solution used for the destruction of controlled drugs. The home has a privacy and dignity policy and this topic is covered on induction. Due to their mental frailty no resident has their own phone but should anyone request this it is available. All residents were appropriately dressed in their own clothes. Any visiting professional including the G.P. will see residents in the privacy of their own room. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 10 Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 11 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) 14 Residents are helped to make choices by their relatives and friends due to their mental frailty. EVIDENCE: The manager stated that not many of the residents have the capacity to exercise personal autonomy and choice and the home relies on the relatives and representatives to help. No resident is capable of handling their own money and all the relatives help with this and a couple of the residents have solicitors acting on their behalf. The bedrooms of the residents all had personal possessions and what comes in to the home is agreed with the manager to ensure it complies with fire regulations if it is a piece of furniture. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 12 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) 18 Staff has a good knowledge of Adult Protection issues, which protects the residents from abuse. EVIDENCE: The staff that the inspector spoke with all had a good knowledge of adult protection procedures and how to report allegations or suspicions of abuse. However the inspector found that their local policy produced by the company does not match Surrey’s policy, which the manager stated they followed. The manager and all registered nurses have received training from Surrey and this information is then cascaded to the rest of the staff. The home has copies of the Surrey Multi Agency procedures on both of the units but the manager needs to ensure that she updates this policy to the 2005 edition. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 13 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 There is a programme of maintenance and re-decoration, which has improved the appearance and atmosphere in the home. EVIDENCE: The manager told the inspector that there is a continual programme of redecoration. There are only nine rooms left to decorate downstairs and these are done as the room is vacated or the resident can be moved into the snoozlem room on a temporary basis. The home is accessible and safe and there are keypads on all the doors to protect the residents. The home has a well-maintained garden on the first floor and awnings have just been fitted to give the residents protection and shade from the sun. The manager stated that in good weather the residents could access the garden easily. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 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) 28 There has been a period of considerable instability in staffing but now the home has a more stable work force offering consistency of care within the home. EVIDENCE: The manager explained to the inspector the recent problems she had with staff turnover and this had also been reported to her through notices to the office. Through an agency she has been able to recruit new carers from abroad and also recruited some more registered nurses. From the original staff only eight are left with NVQ level 2 but the manager has managed to secure a place on the next course and ten staff will be able to do this. Two carers have NVQ level 3 All trainees are registered on a TOPSS certified training programme. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 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) 33 & 35 The home is run with the residents in mind and their financial interests are safeguarded. EVIDENCE: The manager stated that it is not possible to do resident surveys to seek their views but she has put other things in place. She holds regular resident and relatives meetings and these are normally well attended. She told the inspector that she also has an open door policy so relatives and friends are always welcome to speak with her. The manager has a comprehensive business plan, which has been implemented for this year and is continually reviewed. The homes policies and procedures are updated. The inspector saw the notice displayed on the door to inform all visitors of the forthcoming inspection and the inspector had also received feedback sheets. Any relative or representative or relative can set up a pocket money account at the home. The money is kept in the homes safe. A ledger is kept and every Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 16 transaction is noted and signed for. There is a separate envelope kept for each residents money. The envelopes that the inspector sampled were all found to be correct. Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 17 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 3 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 x 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x 3 x 3 x x x Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 18 Are there any outstanding requirements from the last inspection? 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 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 Good Practice Recommendations Jubilee House H09 H58 S17619 Jubilee House V239604 200905 Stage 4.doc Version 1.40 Page 19 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. 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