Inspection on 06/08/07 for Jubilee House

This inspection was carried out on 6th August 2007.

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 21/05/08

Jubilee House 06/06/06

Jubilee House 25/10/05

Jubilee House 19/04/05

Jubilee House 20/10/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Jubilee House Jubilee House Bronshill Road Torquay Devon TQ1 3HA Lead Inspector Michelle Finniear Unannounced Inspection 6th August 2007 06:45 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 DS0000061444.V343881.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 DS0000061444.V343881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee House Address Jubilee House Bronshill Road Torquay Devon TQ1 3HA 01803 311002 01803 311525 jubileemanager@adlcare.com 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) ADL Plc Mrs Eileen Grace Pope Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection June 2006. Brief Description of the Service: Jubilee House provides care for up to 28 people over the age of 65. It is a detached property, set in an accessible garden, with mature trees, close to Torquay town centre. All accommodation is in single rooms, 15 of which have an en suite toilet. There are two bathrooms and an accessible shower. There are some small steps and a slope on the upper floor, but the shaft lift is one side of the building, and the stair lift the other end, to give access to all parts of the building. There is a lounge, a dining room and a bright sun lounge. The current range of fees is £293.97 - £345.00. Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a summary of a cycle of Inspection activity at Jubilee House since the last key inspection visits to the home in June 2006. To help CSCI make decisions about the home the owners and care manager gave us information in writing about how the home is run; documents and correspondence submitted since the last inspection were examined along with the records of what was found at the last inspection; a site visit, starting at 6:45 am was carried out with no prior notice being given to the home as to the specific date and timing of the visit; discussions were held with the manager and staff on duty; various records were sampled, such as care plans and risk assessments; questionnaires were sent to staff who work at the home; a tour was made of the home; discussions were held with visitors and visiting professionals during the day; and time was spent with the people who live at the home both individually and in groups. In addition a sample group of people living at the home were selected and their experience of care was ‘tracked’ and followed through records and discussions with staff and management, looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. Time was then spent with some of these people where possible. This approach hopes to gather as much information about what the experience of living at the home is really like. During the visit some initial discussion was held concerning several anonymous complaints made to CSCI about the home. Investigation into these issues is being undertaken by the homes management and comment on the findings will be included in the next inspection report. Four people living at the home or their relatives completed questionnaires about the home and eleven members of staff. What the service does well: Jubilee House is bright and clean, well decorated and comfortable. The building is well maintained with many bright and airy rooms. There are a variety of communal areas for people to enjoy, including a large conservatory , and outside garden areas. Parking is available at the home or on nearby streets. Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 6 People living at the home eat a good diet, and the meals are adapted to cater for people who have special dietary needs. Meals are home cooked using local suppliers in many cases. A programme of activities is available which some people spoken to said they enjoyed. Others felt they would enjoy more trips out. A recent fete held has raised money which will be used to provide more trips out and activities. The home has access to a new company training manager and has a programme of staff training available. People spoken to about their care generally were happy with what was being provided. One commented that the care offered was “good and all the staff were very friendly”. Another said that the staff were helpful and that there was a good atmosphere, and another that “The home and support is good”. What has improved since the last inspection? What they could do better: Fire doors must not be propped open by devices or objects other than those approved by the local fire authority and the homes own fire precautions risk assessment. This is to protect people from fire. The care plans must be expanded to include the involvement of each person living at the home wherever possible, agreed and signed by them (or their representative), and include in detail action which needs to be taken by care staff to ensure that all aspects of their personal and social care and their Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 7 lifestyle choices and preferences are met. This will help to ensure that peoples needs are met consistently and in a way they wish. The registered person must ensure that service users are safeguarded from abuse, in accordance with written policies. This includes the training of all staff in adult protection and making policies and information available on what to do if abuse is suspected. This is so that all staff working at the home are aware of what is abusive practice and what they should do about it. A suitable place for cleaning commode pots must be provided. This has been a requirement at previous inspections. It is understood that a date has been agreed for the implementation in the near future, and a site has been identified close to the homes laundry room. Full induction plans must be provided for staff. This helps ensure staff are aware of the working practices at the home and can work consistently to support people living there. Staff at the home must be appropriately supervised. This is so that they are working to their full potential and in the same way with people who live there. The Registered Provider should arrange for an assessment of the premises and facilities to be made by a suitably qualified person in respect of disability equipment and environmental adaptations. Sealed bins or bags should be used for storage or movement of potentially contaminated waste or used continence pads. This is to minimise any risks of cross infection. Communal activities such as hairdressing should not be occurring in peoples private rooms. This is to respect peoples private space. 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. The summary of this inspection report can be made available in other formats on request. Jubilee House DS0000061444.V343881.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 DS0000061444.V343881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6. Quality in this outcome area is good. People are fully assessed before they enter the home, which helps to ensure their needs can be met. Information is available about the home to help people make a choice about whether it is right for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and a service user guide available. The service user guide is written for people living at the home or people thinking about moving in and contains details about services and facilities available and about any rules or restrictions. The manager confirmed this would be available in formats such as large print or on audiotape on request. Copies have been issued to everyone at the home. Discussion was held with the manager on the homes admission process for both planned and emergency admissions. The file for the most recently Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 10 admitted person was also examined. This file showed evidence of a preadmission assessment having been completed. Pre-admission assessments are important as they allow the home to make sure they can meet the persons needs before any decision is made about admitting the person. The preassessment had been conducted at a previous home following a review of their care needs. During the visit the relative of this person commented how much they had improved in the few days they had been at Jubilee House and how pleased the family were with the admission. The manager confirmed the family had visited the home on their relatives behalf before making a decision about any move, as the person was unable to do so themselves. The home is not registered to care for people with dementia, however many people living at the home have short term memory loss. The manager indicated this related to about half of the people living at the home. Care Files seen contained copies of contracts which give information on the terms and conditions of residency and gives further information on peoples rights and responsibilities while living at the home. It also gives information on the fees to be paid. This helps to ensure everyone is aware of their rights associated with the placement. The home does not provides intermediate care, which means that it does not provide specialist programmes of rehabilitation as a specialist function. Jubilee House DS0000061444.V343881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. Care plans require attention to make sure that they contain all the information staff need to give care in the way the person wishes. Medication systems are satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection sites visit five files were seen relating to people living at the home. The files seen contained assessments and care plans for each individual. Care plans contain information on support needed for each individual and how that support is to be delivered. They should ensure consistency and a reflection of the individual’s wishes in relation to how their care is to be delivered. Jubilee House is in the process of amending and improving the care planning systems in use. and both of the new and old systems could be seen in the file. Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 12 Two files were selected for particular inspection, and these were then discussed with members of staff to ensure that the care identified in the file was the care that was being delivered. Staff had a good understanding of the needs of the people they were caring for, and plans were very good reflection of the care being delivered. However not all areas of the care plan had been completed fully in files, including support worker plans and there was little information on individual wishes and social and personal histories of people living at the home. In addition for one person discussed, the file would benefit from an assessment of a person’s particular behaviours that were challenging and a management plan being formulated to address this. This would help to ensure that staff were handling this situation in a consistent fashion. Care plans were being regularly reviewed. Files contained information on people’s health care needs, and evidence could be seen of visiting support services to the home, for example district nurses and general practitioners. The home also has a high number of people with continence management issues. The manager confirmed there are regular toileting programs in place and assessments are completed, in some cases with the support of community continence advisor. Evidence of this could be seen during the day. Moving and handling equipment is provided and assessments are undertaken to ensure that people who need support with moving and handling such as hoisting or bath hoists can have their needs met in safety. Pressure relieving equipment is also available, including specialist beds, mattresses and cushions to reduce any risk of pressure areas developing. The home can cater for catheters and district nurses deal with any invasive procedures such as the use of enemas or suppositories. Storage and administration were seen for the medication systems at the home, and a member of staff was also observed giving medication to service users. All medication given is signed for by the member of staff administering it to people living at the home, and medication is supplied to the home in a series of blister packs, which are prepared by the supplying pharmacist. This system aims to reduce any potential error in administration and enables staff to easily check medication has been given and the stock balance. The home has a policy available on homely remedies, which is medication is available to purchase over-the-counter, and a series of first aid kits are situated throughout the home. People spoken to about their care generally were happy with what was being provided. One commented that the care offered was “good and all the staff were very friendly”. Another said that the staff were helpful and that there was a good atmosphere. But one also said that the staff were too busy to spend much time with them, and one commented that a “member of staff keeps them waiting” when they need support. Jubilee House DS0000061444.V343881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. Routines at the home may not be flexible enough to cater for peoples individual wishes and lifestyle choices, which currently are not identified in their care files. Good home cooked meals are provided to meet peoples wishes and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People seen on the inspection site visit at Jubilee house varied considerably in their needs, from some people who were very dependent on staff for most of their care through to others who were more able and wished to be as independent as they could. The site visit was timed to start in the early morning when people would be getting up. On arrival at the home at 6:45 a.m. eight people were already up and washed and dressed, and fast asleep in their rooms or seated in the homes lounge. At least another six were awake in their rooms, with lights and televisions on, but their rooms were not entered to respect their privacy. No information was available in people’s files to indicate that it was their Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 14 preference to be woken so early. Discussion was held on this with the manager, and the staff on duty. Discussion was also held on the benefits of obtaining information from people living at the home about their preferred and lifestyles and how these can best be followed. This would include full information on hobbies and interests and how they like to spend their day. The information supplied for this inspection by the home says that they plan to introduce lifestyle and social planning with better information gathering on people’s needs. This may include one-to-one activities as well as group based activities, as many people who are frail do not work well in groups. This will be a positive development. Activity plans are available at the home and in peoples files, and a recent fete raised considerable money for service user trips and outings. One persons file showed their activities consisted of a weekly bingo session, visits from their daughter, a monthly sing-a-long, fortnightly activity and exercise. There was no information on how this person chose to spend the rest of their time or the patterns and lifestyle they wished to follow. Several of the people spoken to chose not to mix with other people at the home. They said they enjoyed spending much time in their rooms, watching television, or reading. One persons file contains information on their specific communication needs, which included instructions such as speaking slowly in their line of vision, allowing time to express their needs and using closed questions. This is good practice. Discussion was held with the cook on the menu provision. At the time of the site visit the home has a number of diabetic people living there, one person with a lactose intolerance and another with swallowing difficulties. The cook confirmed she has completed nutritional courses and could describe the efforts made to ensure that a good quality diet is available for all the people living at the home. Menus demonstrated a good variety and choice of food is available, including three roast meals a week which is in accordance with people’s wishes. People spoken to were complimentary about the food offered. One persons room was being used by the hairdresser during the course of the day for all of the people living at home. The hairdresser said the person had been asked and did not mind but this is not an appropriate use of private accommodation. Management later confirmed that they had approached the person whose room it was and their advocate before this commenced. In one room seen, information on three people needing hoisting was on display on a wardrobe door. This is a breach of confidentiality and privacy for the other people concerned. Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 15 Jubilee House DS0000061444.V343881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is adequate. Systems are in place to manage complaints. Adult protection procedures are in place but additional training is required to make sure that all staff understand what to do if abuse is suspected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure which is contained within the service user guide. The procedure includes information on stages in making a complaint, including timescales for response from the management. A complaints log is available in the entrance foyer and discussion was held with the manager on whether this is the most confidential way to record and manage complaints and concerns. Prior to this inspection two anonymous written and three anonymous telephone complaints had been received concerning the home. The complaints related to people being got up early, concerns about the management issues, and care of people living at the home. At the time of the inspection these complaints are being investigated by the homes senior management and comment on them will be included in the next report. Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 17 Discussion was held on adult protection procedures within the home. The home has a copy of the most recent locally issued policy and guidance in an updated format, and have copies of other policies such as a Whistle blowing policy. Training has been given to staff on adult protection. Staff spoken to were not clear about the homes adult protection procedures, and were not aware of the homes Alerter’s guidance or whistle-blowing policy. The majority of the returned questionnaires indicated that the staff were familiar with the local adult protection procedures, but three said they were not aware of them. The staff group had received training done by a manager within the organisation, but had not received external training on Adult protection. The manager confirmed this is to be re-enforced in the near future. Jubilee House DS0000061444.V343881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. Jubilee House provides an attractive place to live and work in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the first site visit the tour was made of all areas of the home. Jubilee house provides a comfortable environment which is maintained in good order. The home has a plan for refurbishment to certain areas, which includes the flooring to the approach to the kitchen, and replacement of a carpet in the conservatory. At the time of the visit repairs were being made to the fire escape, and he homes handyman could demonstrate the system for alerting him to maintenance issues and his management of the same. This helps to ensure that any problems are remedied quickly. Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 19 During the course of the early-morning visit to the home a number of Fire doors were being propped open by cushions and walking frames. This puts people at risk in case of a fire and an immediate requirement was left in relation to this area. In addition laundry that had been completed during the night was also hanging on the outside of doors. This could protect present a fire risk and stop some Fire doors from closing appropriately. An immediate requirement was also left in this area. The legionella assessment of the premises is due to be completed in the near future and the manager stated that the best of her knowledge there was no asbestos in the building. She also stated that window restraints have been fitted to all windows, which holds protect service users from accidentally falling from them. Additional door guards are being provided, which means that doors may be safely held open in areas to be approved by the Fire Officer. The home has some parking to the front and an enclosed garden area to the rear. People spoken to said they did not use the garden much as the grass was uneven and hard to walk across. The manager confirmed that a price has been given for balustrading around a patio which should make this area safer for people to use. Bath temperatures tested at random were satisfactory, with wash hand basins and baths being either fitted with automatic regulators or having their water temperature controlled through the boiler. This is important as it protects service users from being scalded by water that is too hot. The last recorded test had been carried out on the 24th July 2007. Peoples rooms showed evidence of their personality and interests, and several had bought items of small furniture or personal belongings to make the room feel more like home. All areas of the home seen on this inspection were clean, and limited odours associated with continence management were isolated to two bedrooms. The handyman cleans wheelchairs and light pull cords, and carries a three monthly building audit and monthly smaller audit out to make sure that all areas of maintenance are maintained. The laundry was clear of obstruction, however an un-lidded bin was seen being taken through the home containing soiled incontinence pads. This could present a cross infection risk. Equipment such as gloves and aprons is available to protect people, living at the home and the staff from risks of cross infection. Jubilee House DS0000061444.V343881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. The staffing arrangements are satisfactory, however some work is required to the homes Induction procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files were selected for examination on the site visit. These were selected to reflect the staff on duty at the time of the visit. Two of the staff were then spoken to concerning the care that they deliver for people and training that they have received. In addition another two staff were spoken to concerning their job roles and training received. Files seen contained information on the recruitment processes that had been followed when people were employed by the home. This included information on references and criminal records bureau checks made. These help to ensure that people at the home are cared for by people who are suitable to work with vulnerable adults. Appropriate checks and Information on staff members recruited from abroad was also contained within the files. Discussion was held with the manager on the induction and training systems at the home. In one file seen, the home had a basic induction sheet, recording the initial training given to staff when they started at the home. The entries Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 21 made were not dated and had only been signed by the manager so it was not clear as to the staff’s participation in that process. The manager confirmed that a new training manager has been employed by the company and they aim to improve the training and induction plan in the near future. A training matrix is to be completed indicating areas where priority training is needed for all staff. The manager confirmed that currently the homes priorities are moving and handling updates for all staff, dementia training and adult protection. Since the last inspection the manager stated they have improved staff turnover and decreased the use of agency staff which helps to improve consistency of care. Staff rotas seen and discussed indicate staff work long hours and staff said the current rota means that on occasions staff work a long stretch without a day off. Staff confirmed re-adjustment of this rota is also a priority for them. Discussion with a member of the night staff indicated that they had completed an induction and have received training in Care of chemicals hazardous to health, Protection of vulnerable adults, moving and handling, and health and safety, and are completing their NVQ level 2. NVQ’s are a national award recognising the competency of care staff in their working role. Another member of staff spoken to is undertaking an assessor’s award which will enable them to assess staff in their workplace for NVQ qualifications. More than half of the staff group have achieved an NVQ level 2, and another 4 are working towards this level or higher. The manager stated that she aims to hold staff meetings twice a year, however records seen indicated the last meeting had been held in October 2006. Some staff who completed questionnaires expressed concerns over some practice issues at the home and these were similar to those expressed in the complaints received which are under investigation by the homes management. Comment on the investigation of these will be included in the next report. Staff who completed questionnaires said they wanted more time to engage with the people they were caring for and more opportunities for professional development. One commented “I feel more like a cleaner than a care assistant”. Another wrote “The care home has given me the chance to work with vulnerable adults, to look after them and it’s a great experience”. Jubilee House DS0000061444.V343881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is adequate. A number of effective management systems are in place to support people living at the home. Development is ongoing to the homes quality assurance system and staff supervision systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions were held with the manager and a number of records were seen on the site visit in relation to the management of the home. These included some policies and procedures, information on the homes quality assurance and supervision systems and fire records. Some policies requested were in a development or review stage. Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 23 The home has commenced a programme of supervision for care staff. The supervision system in place at present is mainly focused on observation and competency issues with staff and does not address issues of practice, philosophy or career development needs. It is understood that a new format for supervision is being implemented a copy of which could be seen. This focuses more on a combination of personal development and workload/policy issues which should help to ensure that staff are working consistently and to their maximum potential in supporting people living at the home. Supervision is currently being carried out every two months for each member of staff and in addition the home has an appraisal system with action plans for any areas identified for development. The home has also started a quality assurance programme and staff questionnaires and questionnaires for other stakeholders such as doctors and district nurses have now been sent out for this year. Results from the last quality assurance questionnaire have been collated into a graph and are available in the service user guide. The questionnaire in use would benefit from additional development and it is understood this is planned along with including information from the homes internal audit systems. A quality matrix is also being provided, which will help the homes management identify what is working well and what could be improved. Discussion was held on maintenance and health and safety issues within the home. The manager confirmed that in the near future portable appliance testing will be carried out. Records for fire drills and alarm testing were seen, and the manager stated that a new gas safety certificate was due to be provided next year. A new boiler is due to be fitted at the home and there is an annual service contract for the lift and moving and handling equipment. Jubilee House DS0000061444.V343881.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 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 3 Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 OP38 Regulation 23 Requirement Timescale for action 06/08/07 2. OP7 15 Fire doors must not be propped open by devices or objects other than those approved by the local fire authority and the homes own fire precautions risk assessment. 06/10/07 A plan of care should be drawn up with the involvement of each resident, agreed and signed by them (or their representative), setting out in detail action which needs to be taken by care staff to ensure that all aspects of their health, personal and social care are met and their lifestyle choices and preferences are met. The registered person must ensure that service users are safeguarded from abuse, in accordance with written policies. This includes the training of all staff in adult protection and making policies and information available on what to do if abuse is suspected. A suitable place for cleaning commode pots must be provided. Previous time scale 30/11/04. (It is understood that DS0000061444.V343881.R01.S.doc 3. OP18 13 06/10/07 4. OP26 23(2k) 06/11/07 Jubilee House Version 5.2 Page 26 this is in hand) 5. 6. OP30 OP36 18 18 (2) Full induction plans must be provided for staff. Staff at the home must be appropriately supervised. 06/11/07 06/10/07 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 OP21 Good Practice Recommendations The Registered Provider should arrange for an assessment of the premises and facilities to be made by a suitably qualified person in respect of disability equipment and environmental adaptations. Sealed bins or bags should be used for storage or movement of potentially contaminated waste or used continence pads. Communal activities such as hairdressing should not be occurring in peoples private rooms. 2. 3. OP26 OP12 Jubilee House DS0000061444.V343881.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000061444.V343881.R01.S.doc Version 5.2 Page 28 - 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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