Inspection on 07/05/07 for Jubilee Lodge

This inspection was carried out on 7th May 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jubilee Lodge 08/03/06

Jubilee Lodge 23/05/05

Jubilee Lodge 01/09/04

Jubilee Lodge 04/05/04

Jubilee Lodge 18/10/03

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

CARE HOME ADULTS 18-65 Jubilee Lodge Grange Farm High Road Chigwell Essex IG7 6DP Lead Inspector Sarah Buckle Unannounced Inspection 7th May 2007 09:40 Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 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 Lodge DS0000015394.V336352.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 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 Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee Lodge Address Grange Farm High Road Chigwell Essex IG7 6DP 0208 5012331 0208 5599583 stump@vitalise.co.uk 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) Vitalise Stephen Clifford Trump Care Home 36 Category(ies) of Dementia - over 65 years of age (30), Physical registration, with number disability (36), Physical disability over 65 years of places of age (36) Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Persons of either sex, aged 18 years and over, who require nursing care by reason of a physical disability (not to exceed 20 persons) Persons of either sex, aged 18 years and over, who require care by reason of a physical disability (not to exceed 30 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 30 persons) The total number of service users accommodated must not exceed 36 persons People with dementia must not be accommodated at the same time as younger adults, those under the age of 65 years, who have a physical disability Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 36 persons) Date of last inspection Brief Description of the Service: Jubilee Lodge is a holiday home offering personal and nursing care to people with physical disabilities. It is situated in a semi rural location with good links via a private road, to bus routes and the London underground. The main shopping area, which also has places to eat and drink, is approximately one mile away. Jubilee Lodge is one of five similar holiday homes that are owned and run by Vitalise. Each home has a different focus to the type of holidays it offers. Jubilee Lodges focus is trips to London, Kent and over to France. There are various themed weeks throughout the year, and these are detailed in the yearly brochure. Jubilee Lodge has twenty-six single rooms and five double rooms all have ensuite facilities. All guest areas are on the ground floor of the building, with staff accommodation on the first floor. Jubilee Lodge has ample parking facilities to the front of the building. The grounds encircle the home. There are formal gardens with ornamental ponds and a wild flower garden with a large pond. The home also overlooks the adjoining Riding for the Disabled training ring. It has its own coaches and mini buses to transport the service users on the trips. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced key inspection. As part of the inspection a visit was made to Jubilee Lodge on 7th May 2007. The visit was carried out by one inspector and lasted five hours. Jubilee Lodge is a holiday home and does not have permanent guests; because of this some of the National Minimum Standards are not applicable to the service. These areas are therefore not taken into account when assessing the judgement of each outcome area. The overall care and well being of the guests was very good. Staff, guests and relatives were welcoming and happy to talk to the inspector. During the site visit, guests, relatives and staff members were spoken with. The registered manager and the deputy manager were also spoken with. A tour of the building was undertaken and relevant documents and records were also examined A number of questionnaires were completed and returned to the Commission. What the service does well: What has improved since the last inspection? Homely remedies are now checked on a weekly basis. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 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 Lodge DS0000015394.V336352.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests are not placed at Jubilee Lodge unless a full needs assessment has been undertaken. The assessment involves the individual and their family or representative. The centre ensures it can meet the assessed needs of the guests prior to their stay. EVIDENCE: National Minimum Standard 2 is the key standard for this outcome group and is not applicable to Jubilee Lodge as it is a holiday home. Bookings are made through the head office as with any holiday booking. However, three booking forms were examined during the inspection site visit and these contained comprehensive information regarding each individual. The clinical lead was spoken with and she stated that if guests are booked and have nursing needs, then the registered nurse assesses these needs. If a guest is booked without nursing needs, a carer trained to NVQ level completes the assessment. One Relative spoken with stated that this was the first time her husband had visited the centre. She said that the staff members are all very good and Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 9 helpful and that all areas of the centre get four out of five, as they are very good. She also stated that all people are equal within the centre. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Jubilee Lodge involves individuals in the planning of care that affects their lifestyle and quality of life. Staff members understand the importance of residents being supported to take control of their own lives. Individuals are encouraged to make their own decisions and choices EVIDENCE: The week of the inspection was one of two designated Alzheimer’s weeks that are run by Jubilee Lodge and therefore the guests were at the home with their carer. Three care plans were examined during the course of this inspection. All of these were completed thoroughly, detailing the individual needs of the guest. Copies of care plans from the guests residential home were included where appropriate, a relative had also added information and there was a copy of the booking form, which was thoroughly completed and signed by the guest. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 11 Although the guests only stay at Jubilee Lodge for a period of one week, the detail within the care plan was specific i.e. one guest had support needs identified regarding speech and the care plan stated “Sometimes speaks lucidly but often loses train of thought”, and support needs regarding dementia were, “Can become confused if there is a sudden change of situation”. The support needs were directly linked to those established during the assessment of the individual. Guests at Jubilee Lodge are able to make choices about how to spend their time. A staff member was spoken with in depth and they stated that the activities at the home are arranged on a weekly basis and are adapted to meet the needs of the guests. They said that as this week was Alzheimer’s week, a lot of the evening entertainment is geared towards an older audience. The previous week they had had karaoke nights, this week they had a ‘1940’s style’ group. The registered manager stated that risk assessments regarding health and safety are undertaken for each individual guest. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are involved in meaningful daytime activities of their own choice. They can access and enjoy opportunities available in the local community. EVIDENCE: As this is a holiday home, issues of ‘Education and Occupation’ National Minimum Standard 12, and National Minimum Standard 15 are not applicable to this client group. Jubilee Lodge gears the activities to the needs of the guests who are staying there. For example, during Alzheimer’s week, the activities were catered towards this client group and included such outings as, a visit to Chigwell Fete, Colchester Zoo, and the Museum of Childhood, to a nature reserve, to Southend and to Romford Market. On the day of the inspection, sixteen Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 13 people were going to visit Southend and fourteen further people were going to Fisher’s Green nature reserve. One relative of a guest said that the care staff at Jubilee Lodge are very good and leave them alone to do what they like whilst still offering help and support. She said that they are able to make choices about what they want to do while at the home. Alongside a choice of two visits each day, evening entertainment is also provided, with the bar being open between 8pm and 11pm. One evening there was the option to attend a theatre show in London. The home also provides an entertainments room with a projector for films and a piano, and a quiet room for reading, watching videos and using the computers, which are connected to the Internet. The dining area within Jubilee Lodge is large and airy. It is a pleasant environment. There is a choice of menu available and guests can chose between two meat dishes, a fish dish and a vegetarian option. The registered manager stated that guests are generally asked in the morning what they would like for dinner. One guest spoken with stated that “The food is nice”, a relative spoken with also said that the food is good. A second relative said that food is labelled for people with diabetes. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal health care needs including specialist health, nursing and dietary requirements are clearly recorded in each guests plan. Personal support is responsive to the varied and individual needs and preferences of the people who use the service. EVIDENCE: The guests at Jubilee Lodge are awarded temporary resident status with a local GP. Support is provided to guests in the manner they prefer. For example, one care plan states regarding night care that the person is not able to use the buzzer, that they require 3 night checks, do not require night turns and they have no medication needs overnight. The guests are given the option of having male or female carers, asked whether they prefer a bath or a shower. During Alzheimer’s week, most guests and their carers take responsibility for medication administration. There are documents available in relation to selfJubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 15 administration of medication, which state that the guest takes full responsibility for administering their own drugs. Each guest has a medical certificate, which states any diagnosis, any current medication and past medical history. This is signed by their GP. The MAR file was examined during the inspection. There is a medication sheet for all guests and a medication administration record (MAR) sheet if medication is administered. These were inconsistently completed regarding the level of detail included. Some did not state the amount of medication received and returned, whereas others did include this information. As the MAR sheet is the only means of auditing medication entering and leaving the home, it is important that all of the appropriate information is recorded. One guest did not receive their medication at breakfast time on 07/05/07 and the MAR sheet was not completed. The member of staff responsible explained that the guest had been asleep and then went out on an early trip, therefore missing their medication, however, this was not recorded on the daily observations document. During the inspection, an ‘O’ for omission was added to the MAR and the daily notes were updated. There were no controlled drugs at the home at the time of the inspection, however, the register was examined and this was completed appropriately. The room temperature within the ‘surgery’ where the medication is stored was 28 degrees. The temperature for storing medication should not exceed 25 degrees. There was no daily temperature recording in place; however, a system for this was devised during the inspection. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The centre has an open culture that allows guests to express their views and in concerns in a safe environment. Guests and others involved with the service are safe and well supported by an organisation that has their protection and safety as a priority. EVIDENCE: There is a written and verbal complaints system in operation at Jubilee Lodge. The pro forma for verbal complaints was examined, and this contained information regarding the name of the complainant, their status, date the complaint was received, details of the complaint and action taken. The registered manager stated that some complaints go directly to head office and are dealt with by them. The complaints and compliments log was examined and this demonstrated that a clear system was in place. Initially a letter is sent explaining that the complaint will be investigated and a response will be sent within 28 days. All complaints are responded to within 28 days. Two complaints have been made to the Commission since the last inspection. These have been dealt with appropriately by the home. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 17 There has been one allegation of abuse raised since the last inspection, however, the correct procedure was implemented and the matter is now closed. All volunteer staff members at the home undertake POVA training as part of their induction. Permanent staff members complete a week of training in January each year and this includes POVA training. One staff member spoken with was clear of the procedure to be followed were an incident of abuse suspected. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Jubilee Lodge provides a physical environment that is appropriate to the specific needs of the people who visit. The well-maintained environment provides specialist aids and equipment to meet the needs of the people who use the service. The centre is well-lit, clean and tidy. EVIDENCE: A tour of the premises was completed as part of the inspection. Overall the home was maintained to a good level, well lit and clean. The home has an entertainment room with a bar, a coffee bar, a quiet room and a sunroom. All of the communal spaces were homely, and staff members were observed interacting with guests in a supportive and friendly manner. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 19 Two bedrooms were seen during the inspection and these were appropriate to the needs of the guests at the home. All of the rooms are en suite and have tracking for overhead hoists. Sixteen rooms have these in place. Each bedroom has a TV and tea and coffee making facilities. A room brochure explains life at Jubilee Lodge to the guests and contains the statement of purpose. Comments and complaints information is displayed within the rooms. The home was clean and there were no odours noted on the day of the site visit. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have confidence in the staff members that care for them. There are consistently enough staff available to meet the needs of the people using the service. The staffing structure is based around delivering outcomes for the people who use the service, and is not led by staff requirements. EVIDENCE: Three staff recruitment files were examined during the site visit to this service. All three were files for newly recruited staff members. One of these contained all of the required information, and had evidence to demonstrate that appropriate checks were completed prior to their employment. The second file seen had evidence of their CRB check being returned prior to employment, however, there was no proof of I.D. contained within the file. The third file was for a dining room assistant who the registered manager said was working under supervision. The CRB check for this staff member had been applied for, but had not yet been returned and although a POVA first check had been Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 21 applied for, this had not been confirmed as clear prior to the person starting employment. This staff member began work on the date of the site visit, and during the course of the day evidence of POVAfirst clearance was emailed to the home. Staffing levels within the home were appropriate. During the site visit, the registered manager, the deputy manager, the clinical services manager, a duty nurse and five health care assistants were on duty. Volunteers who work at the home for periods ranging from one week to six months supplement this staff team. Volunteers are recruited at head office. The home currently has four staff members who have completed the NVQ2 and three who have completed NVQ3. Alongside this, one person is registered to begin the NVQ3 and six further staff members are registered to complete NVQ2. The deputy manager has started the registered managers award recently, and the registered manager has started the NVQ4. All staff members receive training in key areas such as manual handling, POVA, infection control etc during the home’s period of closure in January of each year. The induction programme is comprehensive and includes such areas as personal care, pressure area care, elimination needs, nutritional needs, moving and handling, infection control, storage, operation and maintenance of equipment, wheelchair safety, documentation, 1st Aid, responsibilities to volunteers etc. As each section is completed the inductee and the assessor sign it. A new member of staff will also shadow another member of staff for two weeks. Once they are hoist trained they are given their uniform and more responsibility. One member of staff spoken with said that induction at the home is thorough. Three team leaders take responsibility for supervising their teams, and they in turn receive supervision from the clinical services manager. A member of staff spoken with stated that they aim for six each year, but don’t always manage this and that it is probably more like three monthly. Two staff files were examined in relation to supervision and both of these had evidence that one 1:1 had taken place. Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. EVIDENCE: There is a clear management structure within the home. The manager was registered with the Commission in October 2005. He has started his NVQ4 and worked at the home as manager since 1985. Members of staff spoken with all commented on the fact that he is accessible and supportive. One staff member said that there is an open door approach within the home and that it is not hierarchical because everyone works together to do what is needed. A Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 23 second member of staff spoken with said that there is always someone around to approach if need be, the managers are always present. The deputy manager stated that a steering group has been developed to implement the PQASSO quality assurance system into the home. This started in February 2007 and the group meet once a fortnight to work on this. Evidence was seen regarding level 1 of PQASSO, which is concerned with developing a user-centred service. The deputy manager stated that a questionnaire is given to every guest at the end of each week and that this information is sent to head office on a monthly basis. The information is collated and a report sent to Jubilee Lodge so that they can take action to make improvements accordingly. A number of health and safety areas were examined. Risk assessments for the centre were in place and these had been updated in February 2007. These were comprehensive documents, which clearly outline instructive actions to be taken. Evidence was seen of PAT testing taking place between February and April 2007. Fire alarm maintenance was regular and recorded. There was a fire officer inspection at the centre in January 2007. Various other records and certificates regarding health and safety were also examined and these were in date and regular. Jubilee Lodge DS0000015394.V336352.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 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 X 2 3 3 X 4 X 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 N/A 13 3 14 X 15 N/A 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X 3 X Jubilee Lodge DS0000015394.V336352.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 01/08/07 2. YA34 19(1)(b) and Sch 2 The registered person must make arrangements for the recording and safekeeping of medication within the centre. This is in relation to one guest not receiving their prescribed medication and the details not being recorded appropriately, and to MAR sheets having inconsistent information documented on them. The recruitment procedure within 01/08/07 Jubilee Lodge is mainly robust, however, proof of ID and a POVA first check must be received prior to a new member of staff commencing employment. 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 YA36 Good Practice Recommendations Staff members would benefit from regular recorded supervision at least six times each year. DS0000015394.V336352.R01.S.doc Version 5.2 Page 26 Jubilee Lodge Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. 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