CARE HOME ADULTS 18-65
Jubilee House Therapy Centre Eamont Park Eamont Bridge Penrith Cumbria CA10 2BN Lead Inspector
Colette Hibbert Unannounced Inspection 6th February 2006 09:30 Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 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 Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 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 Adults 18-65. 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 Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Jubilee House Therapy Centre Address Eamont Park Eamont Bridge Penrith Cumbria CA10 2BN 01768 890009 01768 891212 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) Fire Services National Benevolent Fund Mrs Jacqueline Southern-Leigh Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4), Physical disability (4) of places Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd August 2005 Brief Description of the Service: Jubilee House is a 41-bed purpose built rehabilitation and therapy centre that is situated next to the river Eamont near to Penrith. This facility is accessible to members and their families of the fire service. Four of the beds are registered with the Commission for Social Care Inspection to accommodate service users who require nursing input during their planned programme of therapy. The remainder of the beds are used by those who are self caring. Potential service users are referred to the Fire Service Benevolent fund via the general practitioner. The registered beds are located on the ground floor in large rooms that enable service users with a wide range of needs to be accommodated and who may require additional equipment in their rooms. Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection commencing at 09:30 and finished at 13:00hrs. The inspection included a full tour of the building, talking with clients receiving nursing care as well as some who were not. Staff were observed and spoken to. Relevant documentation was read. The registered manager was available and assisted throughout the visit. What the service does well:
The aim of the stay at the centre is to either improve or maintain skills and independence of the clients. They try to introduce a healthy lifestyle that can be maintained once the client is at home. The programme is well planned and includes all members of the therapy team and the clients planning a personalised programme for the weeks stay. Clients are encouraged to visit or contact the centre prior to their stay to identify any problems or worries. The centre is constantly adding to the programme sessions on offer to the clients and looking at ways to cater for the needs of each individual. The centre encourages the clients to take part in activities within the local community as well as the leisure activities within the centre. The centre has a robust complaints’ procedures and the clients felt that if they had any concerns they would be dealt with professionally. One client said that he could not imagine ‘what there was to complain about, this place is perfect’ The environment is well designed and meets the needs of the clients. It is light, bright and well maintained. Staff are constantly looking at ways to improve the facilities for the clients. They have a comprehensive audit system in place to identify any areas of weakness and improve on them. Staff are well trained and have clear views of their roles and the direction the centre is moving in. There is a strong management team, which provides leadership and support for the staff. Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 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 Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 4 The pre-admission process is very thorough ensuring that clients make an informed choice before entering the centre. EVIDENCE: The centre has a through admissions procedure for the clients. Welldocumented information within the care plans follows the admission process and information is given to the clients. There is a well-balanced admission pack, which includes literature, a DVD and visits from the centre representatives to the client’s home. The centre takes clients from all over the country but those who wish can visit for the day prior to admission and spend a trial day at the centre. This was confirmed by some of the clients at the centre. Policies have been improved since the last inspection and clients have not been admitted out of registered category. This was a requirement made at the last inspection and has been met Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Clients within the centre are consulted in the care planning and therapy planning process and are fully supported to be as independent as possible. EVIDENCE: The clients within the centre are very much involved and consulted in all aspects of the therapy programme that is planned with them. The programme is planned at the beginning of the client’s week. A timetable is drawn up; this is reviewed regularly and changed with consultation with the client and to suit the client’s wishes. The clients’ spoken to confirm this, the programmes were very individual. One client said that he was not feeling ‘to good’ so he had been given time to rest in his room and the staff had re organised his day’s programme. The staff then monitored him to ensure he is able to continue with his therapy programme. Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14,and 15. Clients are supported and offered many opportunities to take part in a variety of physical activities and complementary therapies based on their individual needs and wishes. EVIDENCE: Clients are offered opportunities for personal development with a wide range of therapies available, including Physiotherapy, Supported Listening Sessions, and Assertiveness, Daily hassles; Sleep clinics, Pain Management, Anger Management, Aromatherapy, Reika, Reflexology, Acupuncture, and Calm Clinic. These are planned within the clients programme. There is a more relaxed agenda during the evening with a choice of leisure activities, relaxing in their own rooms, in the lounge or at the bar. Clients said that they were asked before arriving if they had any requests for activities to be organised for example, shopping trips or hairdressers and this could be included in the programme for the week they were staying in the centre. Clients have to opportunity to take part in the local community with outing to the local pub and into town. Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 11 Social activities are displayed on a notice board, which included a fund raising event to support the national fire fighters Olympics, and another night there was going to be a quiz. Clients are encouraged to make friends and if they wish carers and families can stay at the centre with them. Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not assessed at this inspection EVIDENCE: Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The clients feel that their views are listened to and acted on before and during their stay at the centre. The staff are aware of the policies and procedures in place to protect their clients from abuse. EVIDENCE: Clients spoken to said that they felt as if they were being listened to before they arrived at the centre, with the comprehensive admission procedure and forms they have to fill in prior to admission. Any special requests were adhered to if possible. One client said that before he arrived he has requested the use of an electric scooter, which he was pleased to find ready and waiting for him in his room. Another said he was worried prior to admission, as he did not want to be ‘dictated to’ during his stay. He was very happy that his views and opinions were taken into account and he was constantly being consulted. Staff were very aware of the need to protect their clients from abuse. The staff spoken to said that they were aware of the policy and the procedures to put in place in the event of any resident being put at risk. Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 27 The environment is very clean, and well maintained. The toilet and bathroom facilities are available to enable all residents to retain privacy and dignity and meet individual needs EVIDENCE: The whole of the centre was clean, bright fresh and well maintained. All bedrooms have en-suite facilities. The rooms are furnished to a high standard with bright walls and carpets or wooden flooring. The corridors are wide to allow for easy wheelchair access. The dinning room is very bright and airy with various heights of tables and chair to enable clients to sit comfortably whilst eating. There is an open lounge area at the end of the dining room with a variety of chairs and coffee tables and room for wheel chairs to have easy access. One client said that moving around was not a problem and wherever he went he did not feel that others had to ‘make room for him’ in his wheel chair. Throughout the building there were small areas for clients to sit, enabling them to look out of the low windows and admire the views. Each area had chairs, tables and magazines with plants and flowers to add a touch of interest and colour. There were several communal bathroom facilities all well maintained and clean. Each bedroom has en-suite facilities as well. Two of the rooms used by clients
Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 15 who required nursing care had their bathrooms extended which made access to the easier. One of the clients said that it made him more independent as his electric chair could know fit into the bathroom with ample space to turn in. Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 34 and 36 Staff were very aware of their individual and team role within the centre. The centre has robust recruitment policies and procedures in place, which protect the clients. Staff are well supported and supervised to ensure clients care needs are met. EVIDENCE: Several members of staff were spoken with. Each confirmed that they had full job descriptions and were aware of their own role and how they fitted into the team within the centre. The centre benefits from a very low staff turnover rate. Any vacancies that occur are advertised internally and nationally. A robust interview process is in place. All staff have appropriate Criminal Records Bureau Disclosures, Protection of Vulnerable Adults Checks and two references obtained prior to employment to ensure the safety of the clients. Staff have regular supervision and annual appraisals but felt that they could seek help or advice from there mentor at any time should they need it. They felt that they supported each other well on a daily basis. Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 41, and 43 Clients’ views and opinions are actively sought to improve the services provided for them. There are robust policies in place to safeguard the clients’ rights and maintain confidentiality. There is a strong management team in place to provide leadership for the staff. EVIDENCE: Clients are given several opportunities to give suggestions and opinions about the services the centre provides. They have questionnaires in their rooms and feedback is encouraged during their treatment sessions. Families are also able to provide feed back if they wish. The home has an annual development plan and internal audit system in place to monitor the standard of the service they are providing for the clients in their care. There are policies in place to safeguard the clients’ rights, these are updated annually and staff are aware of them. Staff are updated at staff meetings on any changes to the policies and they have access to the policy file. The centre benefits from a strong management team who run the service well, and are constantly trying to improve the service for the benefit of the clients.
Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X 3 3 3 X 3 Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 19 NO 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. 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. Refer to Standard Good Practice Recommendations Jubilee House Therapy Centre DS0000010096.V282540.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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