Inspection on 15/05/07 for Jubilee Mews

This inspection was carried out on 15th 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jubilee Mews 10/10/05

Jubilee Mews 31/05/05

Jubilee Mews 09/12/04

Jubilee Mews 13/04/04

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

CARE HOME ADULTS 18-65 Jubilee Mews 15-21 Jubilee Road Gosforth Newcastle Upon Tyne Tyne & Wear NE3 3DX Lead Inspector Miss G Gaffney Key Unannounced Inspection 15, 16 and 17 May 2007 02:30 Jubilee Mews DS0000000422.V338118.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 Mews DS0000000422.V338118.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 Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee Mews Address 15-21 Jubilee Road Gosforth Newcastle Upon Tyne Tyne & Wear NE3 3DX 0191 213 0988 0191 2131115 admin@mentalhealthconcern.org www.mentalhealthconcern.org Mental Health Concern 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) Mark Edward Jones Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2005 Brief Description of the Service: Mental Health Concern is a ‘not for profit’ organisation which provides mental health care to adults living in community houses and other residential settings. Jubilee Mews is a registered nursing home that provides accommodation and support to 12 adults with enduring mental health care needs. The home is staffed 24 hours a day by registered nurses and support workers. The home comprises three houses, each with four bedrooms, located in the Gosforth area of Newcastle. The home provides the people living there with easy access to local facilities and transport links. Each house has a lounge, kitchen/dining area, four bedrooms, a bathroom, toilets and a shower room. There is also a conservatory and a large garden to the rear of each property. The fee charged for a place at the home is £685.82. Extra charges are made for hairdressing, chiropody, toiletries and clothes. The most recent inspection report was available on request to people living at the home, their families and visitors. Staff and people using the service are made aware of inspection outcomes during staff and householder meetings. Information about fees charged is included in each person’s contract with the provider. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out: Before the visit: We looked at: • • • • • Information we have received since the last visit on 10 October 2005; How the service dealt with any complaints & concerns since the last visit; Any changes to how the home is run; The manager’s view of how well they care for people; The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on the 15 May 2007. During the visit we: • • • • • • Talked with people who use the service, staff and the manager; Looked at information about the people who use the service & how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills & training to meet the needs of the people they care for; Looked around the building to make sure it was clean, safe & comfortable; Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: The home had: • • • Assessed peoples’ needs to ensure that they could be well cared for at Jubilee Mews. The standard of assessment information recorded was of a good standard; Devised care plans which set out how the home intended to meet the needs of people using the service; Put robust arrangements in place to review and monitor peoples’ placements to ensure that the services being provided were effective; DS0000000422.V338118.R01.S.doc Version 5.2 Page 6 Jubilee Mews • • Set up a gardening project that enabled people to engage in work in a safe and well supported setting. This allowed people to – earn a wage, exercise, obtain positive work experiences and to see the results of their work; Held a ‘Cook-off’ competition between three members of staff. This event helped to boost the morale of people living and working at the home. Staff were willing to work flexibly so that people could enjoy everyday social events without feeling constrained by staff needing to get back to the office because their shift was over. Staff supported people to: • • • • • • Take sensible risks; Make choices and decisions that had a positive effect upon their lives; Live ‘ordinary lives’ in their local community; Work to obtain financial reward and increased feelings of self worth; Develop positive relationships with the people they lived with and to engage in social events arranged at the home; Eat more healthily and manage weight loss in a positive manner. The manager and his staff team: • • • • Adopted a positive approach to the inspection process and were willing to engage in a constructive debate about inspection outcomes; Were interested in developing better ways of working with people by keeping their nursing practice up to date and informed by current developments in mental health research; Were committed to treating people as individuals and to using each person’s unique strengths, abilities and past experiences as a means to moving them towards recovery and a better life experience; Had developed effective working relationships with other professionals involved in the lives of people living at the home. Staff morale was high and there was a strong commitment to providing people with the best possible support. People said that they: • • • Were satisfied with the care and support they received at Jubilee Mews and felt that staff listened to their opinions and views. They also said that staff were kind, respectful and considerate; Enjoyed the meals served at Jubilee Mews; Valued the independence that staff encouraged them to develop. There was a range of communal areas that could be used by people wanting to socialise or have private time to themselves. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 7 A women’s group is held on a regular basis involving female users of services provided by Mental Health Concern. Staff had undertaken Mental Health Capacity Act training. This will enable them to better support people who experience difficulties in making their wishes and feelings known. All grades of staff had a job description and person specification. Staff at all levels receive regular supervision. Mental Health Concern has a Service User and Carer Board and two of the people at Jubilee Mews are active members. The provider’s Visitors Policy was changed following comments made by people attending Board meetings. There is a very low level of staff sickness and staff turnaround. The provider has put copies of Commission inspection reports on its intranet. What has improved since the last inspection? There is a new management team in place. The home had a full complement of staff. Staff have access to better facilities when staying over at the home. The living rooms in each of the houses have been refurbished and new sofas provided. New blinds had been fitted to the conservatory windows. Repairs had been made to the entrance hall ceiling and the laundry had been redecorated in house 15. Staff had worked hard to develop good working relationships with the families of people using the service. Staff had provided relatives with information about mental illness. Staff had encouraged relatives to attend peoples’ reviews. A wildlife garden has been developed for one of the houses. A key worker had completed equality and diversity training. The home had introduced a new referral assessment form to improve the quality of information received about new people wishing to use the service. The provider’s risk taking policy had been revised following input from the Service User and Carer Board. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 8 Following the ‘Running on Empty’ initiative, people living at the home had been encouraged to lead a healthier lifestyle. A number of staff had attended training in safeguarding vulnerable people. 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 Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 9 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 Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 10 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. Satisfactory arrangements were in place to ensure that staff received the information they needed to provide people living at the home with a good standard of care. This meant that staff were able to fully meet the care needs of people using the service. EVIDENCE: Staff said that admissions into the home did not take place until after a full needs assessment had been carried out by specialist mental health professionals. The care records of three people were examined. In two of the files examined, there was neither a Care Management nor, a specialist mental health needs assessment/care plan available; as they had been admitted before such arrangements came into place. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 11 A specialist assessment completed by experienced and qualified mental health care staff was available in the third file checked. The home also carried out its own assessment and had devised a referral assessment format for recording information collected prior to a person’s admission into the home. This document included a prompt to remind the assessor to consider relevant cultural and ethnic background issues. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 12 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, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good care planning and review processes in place. This meant that staff were clear about how they should meet the needs of people using the service. The health care needs of people living at the home had been satisfactorily met enabling them to lead healthy lives. Staff respected the needs and wishes of people living at the home. This meant that people felt valued and able to retain control over the way they wanted to live their lives. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 13 EVIDENCE: People living at the home had care plans that had either been agreed with them or their family. The care plans examined were easy to understand and had been written in plain English. A member of staff said that the people currently using the service were able to understand the information that had been recorded about them in their care records. This person also said that should anyone experience difficulties understanding what had been written about them, their key worker would spend time trying to help them achieve a better understanding. The care records of three people were examined. These covered such areas as: • • • • Information about peoples’ lives before they came to live at Jubilee Mews; An assessment of peoples’ needs in the seven key areas promoted by the provider - independence, choice, fulfilment, privacy, dignity, rights and citizenship. Peoples’ assessments had been updated on an annual basis; Care plans setting out how the home intended to meet peoples’ assessed needs; A monthly evaluation of how effective each person’s care plans had been in meeting their needs. The home’s key worker system enabled staff to establish a good working relationship with people using the service. It was clear that staff understood the benefits of involving people in the preparation of their assessments and care plans. People had signed the information contained in their care records to confirm their agreement with the contents. There was evidence that reviews of peoples’ placements had taken place every six months. Reviews involved the key professionals working with each person. A person using the service said that he and his father were always invited to attend reviews held by the home. Mental Health Concern had provided its staff with guidance on how to assess and manage risks. The records of a person recently admitted into the service were examined. There was evidence that a copy of the risk assessment information, prepared by the mental health professionals involved with his care, had been obtained before the admission took place. Risks identified after admission had been assessed and care plans put in place. Where risks had been identified in areas such as smoking, staff had completed the home’s formal risk assessment documentation. There was evidence that the manager and his staff team understood the importance of people being supported and encouraged to take control of their own lives and make their own decisions and choices. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 14 For example, one person said that he could choose: • • • • • • How he kept his bedroom and when he cleaned it; Who he socialised with, both within and outside of the home; What he ate and when; When he wanted to sleep; How he dressed; Whether he attended his review meeting. Another person said that staff consulted him about his medication and the plans that had been put in place to meet his needs. Regular meetings are held where staff consult people using the service about such things as how their house is run and what could be done to make it a better place to live in. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 15 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. Suitable arrangements were in place supporting people to maintain contact with their families and friends. This meant that people could choose to continue with those relationships which they valued most after moving into the home. Satisfactory opportunities were in place enabling people to involve themselves in the home’s day-to-day domestic routines. This meant that they could practise and develop the skills required to live independently. People living at the home were supported to make positive and informed choices about the meals they ate. This meant that people were encouraged and enabled to eat healthy meals and live healthier lives. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 16 EVIDENCE: People living at the home had been provided with opportunities to develop and maintain important personal and family relationships. Assessments contained information about peoples’ families and friends. Staff spoke of how they worked in partnership with families to enable them to maintain positive contact with their relative. People interviewed said that they could not recall any restrictions being placed on their visitors. One person said that staff always made his father feel welcome. A visitor’s policy was available. There was evidence that staff had supported people to join in meaningful daytime activities of their own choice. For example, in one person’s records a care plan had been put in place which focussed on supporting her to make better use of community facilities, such as accompanying staff to undertake the weekly shop and attending a local ladies group. Another person had been supported to regularly attend various local social clubs and projects. A person using the service told the inspector that he was always encouraged, but never forced, to participate in local community activities and events. He said ‘the home’s approach suits me as it means I can just get on and live my life the way I want to.’ Assessments completed by staff contained information about how people using the service viewed their own rights and, what had prevented them from fully exercising those rights in the past. A member of staff spoke knowledgeably about the rights and responsibilities of people living at Jubilee Mews. She said that staff supported peoples’ rights to use the same medical facilities as any other member of the community. She also said that people were expected to be responsible for the day-to-day running of their house and to comply with the terms of the Mental Health Concern licence agreement. The manager confirmed that qualified staff had made decisions to curtail the freedom of some people living at the home to protect their mental and physical well-being. Mr Jones said that such decisions had been agreed between the person concerned and their key worker, following which a care plan had been put in place. He also said that such decisions were reviewed during six monthly review meetings. None of the people living at the home had any difficulties with eating or required assistance with eating. There was an expectation that people using the service would be involved in the domestic routines of their house and in the planning and cooking of their meals. One person said that house members were always consulted about what they wanted to eat each week. She also said that they were expected to help out with the shopping and carry out their household chores. A sample of menus was examined. The menus covered the main meal times and included details of the range of foods and beverages available at the breakfast and suppertime meals. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 17 There was evidence that the home promoted healthy eating. For example, staff had provided one person with guidance on how to lose weight by eating healthily. Another person with a diabetic condition had been given information about how to eat a suitable diet that would control his diabetes. A staff member said that a diabetic care plan had been put in place. Also, a dietician had been asked to attend a women’s group run by the home. Each of the people interviewed said that they were very happy with the quality and variety of food served at the home. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 18 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. The health care needs of people living at the home had been satisfactorily met enabling them to lead healthy lifestyles. The systems in place to support the safe administration, storage and disposal of medication were generally satisfactory and promoted peoples’ good health. Where staff had made medication errors, appropriate action had been taken to address and prevent them from happening again. EVIDENCE: The home’s statement of purpose included information about how the health care needs of people living at the home would be met. Peoples’ health care needs are overseen and managed by qualified nursing staff. Staff interviewed spoke knowledgeably about how people using the service were supported to maintain better physical and mental health. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 19 Information about peoples’ health care needs had been recorded in their care records. In one person’s records there was evidence that since the beginning of the year, staff had: - sought medical advice on three occasions; obtained physiotherapy advice about improving their mobility; accompanied him on various outpatient appointments following major surgery; arranged dental appointments. This person had also received optical care in 2006. Two people said that their health care needs were well met both within, and outside of, the home. Only one person required assistance with intimate personal care. A member of staff described how this person’s needs were met and how her preferences were taken into account. Arrangements were in place to provide support workers with health care training where a need to do so is identified. Members of the qualified nursing team usually provide this training. Mental Health Concern had developed a policy that staff were expected to follow when administering medication. The cupboard used to store medication was clean and hygienic. All medication had been properly secured. Photos to identify each person were available in their care records. Records were in place covering the ordering, receipt, administration and disposal of medicines. Controlled drugs were not being administered at the time of the inspection. Only qualified nursing staff administered medication. Since the last inspection of the home (October 2005), there had been: • • • Two incidents where medication had not been properly administered by staff; Four incidents where people had taken their medication incorrectly; Three incidents where staff had not followed the guidance contained in peoples’ medication care plans. The manager confirmed that each incident had been investigated fully. Staff had been provided with support to ensure that such incidents did not re-occur. Peoples’ competence to administer their own medication had been reviewed and their care plans reviewed and modified. The Commission had not been informed of all of the above incidents. Mr Jones said that an experienced pharmacist had not audited the home’s medication arrangements and day-today practices. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 20 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 arrangements in place for handling complaints were satisfactory and people were confident that their complaints would be listened to, taken seriously and acted upon. Satisfactory arrangements were in place to protect people from harm or abuse. This meant that people could feel safe and protected in their own home. EVIDENCE: The home had a complaints procedure that was easy to read and understand. It had been written in plain English. The manager said that people were informed about the home’s complaints procedure on admission into Jubilee Mews. Staff are expected to go through the home’s complaints procedure with each person on a six monthly basis. There are no people accommodated who require the home’s complaints procedure to be made available in a different format. Although the policy contained the required information it did not contain the correct name of the current regulatory body. The manager agreed to address this matter following the inspection. The complaints procedure provided staff with guidance about how to handle complaints. People living at the home said that they would be happy to raise any concerns they might have with the manager or a member of the staff team. Neither the home, nor the Commission, had received any complaints since the last inspection. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 21 The provider’s safeguarding policy provided staff with guidance about how to handle adult protection concerns. Although the policy had been amended following a requirement made in the last inspection report, it still did not include clear enough guidance on how the provider’s vulnerable adults policy and procedures fitted with the local authority’s safeguarding responsibilities. There had been no concerns raised with either the home, or the Commission, since the last inspection. All staff had received training in the protection of vulnerable adults. The provider had plans to provide qualified staff with more in-depth training in the protection of vulnerable adults. People living at the home said that they felt safe and secure. Staff were able to satisfactorily describe the action they would take to protect people from potential harm or abuse. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 22 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. The standard of the environment was satisfactory providing people with a domestic and homely place to live. The overall quality of the furnishings and fittings was good. This meant that people were able to live in a safe, wellmaintained and comfortable environment, which encouraged independence. EVIDENCE: The design of the home enabled small groups of people to live together in ordinary houses resulting in a non-institutional environment. The houses had been adapted to meet the needs of the people living there. For example, there was a ramped access to each of the houses. A qualified member of staff said that no other aids or adaptations were required at present. There were no shared bedrooms and those visited were generally well maintained. People had been given a key to their bedroom door. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 23 People had personalised their own bedrooms in line with their preferred tastes. One person said that his bedroom would be ‘perfect’ if he could have an item of furniture belonging to him sent to the home from the hospital where he previously lived. People had access to communal space where they could mix with others and watch television. Each house had a conservatory and lounge area. People could see family and friends in the privacy of their own bedroom. Each house contained sufficient toilets and bathing facilities. An adapted shower room was available in each house. No other bathing aids were required. An Occupational Therapist had recently visited the home and carried out an assessment of the aids and adaptations required to enable one of the residents to return to Jubilee Mews following hospital treatment. Although the furnishings and fittings provided in each house were of a good standard, some places would benefit from re-decoration such as the kitchen and bathroom areas. The provider intends to undertake this work within the next 12 months. Also, over bath showers are to be installed in each house and conservatory doors will be refitted to take account of new smoking legislation. The houses were safe and free from unnecessary hazards. There were no unpleasant odours. Requirements made following the fire officer’s last inspection of the home had been addressed. The manager said that although the home did not have a written refurbishment and maintenance plan, the systems in place to ensure that the houses were well maintained worked well. The home had an infection control policy. Staff had completed an infection control checklist to ensure that problems in this area were minimised. Each house had its own laundry facilities. No concerns were identified. All staff had received infection control training. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 24 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. The arrangements for ensuring that staff regularly updated their training in key areas were satisfactory. This meant that staff had the skills and knowledge required to meet peoples’ needs in a safe and professional manner. There was a satisfactory programme of regular and structured staff supervision. This meant that staff were properly supervised and received the support and guidance they needed in caring for the people who live at Jubilee Mews. EVIDENCE: An audit of the home’s rotas for May 2007 showed that the following levels of staffing were in place: • • 7.30am to 9am: one member of staff; 9am to 5pm: between four and five staff; DS0000000422.V338118.R01.S.doc Version 5.2 Page 25 Jubilee Mews • • 5pm to 8.30pm: one member of staff; 8.30pm to 7.30am: two staff, one of which provides waking night cover. These minimum staffing levels vary at the weekends. Housekeeping cover was available Monday to Friday. An examination of the rotas showed that extra staff were available during busy times of the day to cover such things as staff training, meetings and medical appointments. A member of staff felt that sufficient staff were rostered on duty until 5pm and this allowed staff to support people to be independent both within the home and in the local community. Another member of staff said that the availability of only one member of staff between 5pm and 8.30pm made it difficult to always provide the range of support required by some people. On-call cover was available outside of office working hours and was provided by qualified staff. The turnover of staff was low and there were no vacancies. Mental Health Concern relief staff had occasionally been used to cover shortfalls in the home’s rota. People living at the home felt well supported by staff. No concerns were expressed about the conduct of staff. Staff had access to a comprehensive training programme that used both inhouse and external training providers. The manager said that he received regular notifications of available training courses. The programme covered the mandatory and specialist training needs of both qualified and non-qualified staff. The manager had access to a database that enabled him to track when staff needed to update their training. A sample of three staff training records were examined and it was noted that all staff had up to date training in the following areas: - moving and handling; first aid; basic food hygiene and fire safety. Two staff had completed health and safety training and one person needed to complete this training. An analysis of staffs’ training needs had been done as part of their annual appraisal. There were eight qualified mental health care nurses working at the home. None of the unqualified care staff had obtained a relevant qualification in care. Mental Health Concern had a robust recruitment and selection procedure that was last reviewed in 2005. Information required to confirm that newly appointed staff had been subject to rigorous pre-employment checks was not available within the home. But, within 15 minutes, the required staff files had been delivered to the home. In the sample of staff files examined, there was evidence that: • • • • An application form had been completed by each member of staff; Criminal Records Bureau disclosure checks and verification of identity were in place on each file; Each member of staff had been given a contract of employment; Staff had confirmed on their application form whether they had any convictions or cautions; DS0000000422.V338118.R01.S.doc Version 5.2 Page 26 Jubilee Mews • Two written references had been obtained for each applicant. Staff meetings had taken place approximately every six to eight weeks and detailed minutes had been kept. There was evidence that staff had received regular structured supervision. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 27 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, 41 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 provided a clear sense of leadership, involved staff and people living at Jubilee Mews in the management of the home and, demonstrated a commitment to providing good quality care. This meant that people lived in a home which was run and managed by a person who was fit to be in charge, was of good character and able to discharge his responsibilities fully. Steps had been taken to promote the health and well being of people living at the home and to protect them from potential hazards. This meant that people lived in a home where health and safety concerns were taken seriously and promptly addressed to prevent them being harmed. There were suitable arrangements for keeping peoples’ money and valuables safe. This meant that people living at Jubilee Mews could be sure that their money and financial interests were being safeguarded. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 28 EVIDENCE: The manager is a qualified registered mental health nurse and had obtained the Registered Manager’s Award. Mr Jones has extensive experience of working with adults with mental health care needs in a variety of settings. There was evidence that the Jubilee Mews staff team worked well together to improve the quality of life experienced by people using the service. Staff felt that the manager ran the home in an open and transparent manner. The home offered care that was focused on the needs of the people living there and staff had established good working relationships with families and other professionals. The manager was aware of current developments in his own field and was interested to know more about the Commission’s ‘Inspecting for Better Lives’ Programme. Mental Health Concern provides it staff with access to an in-house journal club. A member of staff scans professional literature to identify articles that might be of interest to staff working at the home. Unannounced visits to monitor the quality of care and support provided at Jubilee Mews are carried out by the Mental Health Concern Chief Executive every two months. The provider’s Practice Standards Manager also visits the home on a monthly basis to carry out a quality audit. All staff receive regular supervision. Exit interviews are held with student nurses to monitor the quality of the clinical support given during their placement. People living at the home work in partnership with staff during the nursing process from assessment through to evaluations of care plans. The home’s accident record had been well completed. A range of health and safety records was examined. The provider had a detailed and comprehensive health and safety policy and supportive documentation. A tour of the premises identified no health and safety concerns. A range of health and safety monitoring tools had been used to check that the building was safe for people to live and work in. These covered areas such as the safety of electrical appliances through to the use of computer equipment. Those examined were up to date and had been recently reviewed. An audit of the home’s fire records was undertaken and it was confirmed that the required fire prevention checks had been completed. The home’s fire risk assessment had been recently updated and staff had received fire instruction, and participated in fire drills, at the frequency recommended by the fire service. A range of workplace risk assessments had been put in place. But, some of those checked had not been reviewed during the last 12 months. Although staff were sometimes left alone in the building during the course of their shift, a ‘Lone Working’ risk assessment had not been completed. Although the home had taken measures to prevent a Legionalla outbreak, arrangements had not been made for a sample of water to be checked on a regular basis for the presence of Legionella. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 29 External contractors are used to check that the thermostatic valves controlling the temperature of hot water supplied to the home’s bathing facilities are working satisfactorily. The finance records of the people using the service were well maintained. Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 30 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 2 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 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X x 2 X Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 31 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 37 Timescale for action Ensure that all medication errors 01/07/07 are notified to the Commission within 24 hours. Update the home’s medication policy to reflect this requirement. Take pharmacy advice about 01/08/07 whether it is necessary to alarm the home’s medication cabinet. (A requirement was included in the last inspection report requiring the provider to alarm the home’s medication cabinet. The timescale for complying with this requirement expired on 10/11/05.) Ensure that the home’s adult 01/08/07 protection policy and procedures fit with the local authority’s safeguarding duties and responsibilities. Requirement 2. YA20 13(2) 3. YA23 13(6) Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 32 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 YA2 Good Practice Recommendations Ensure that extra equality and diversity prompts are added to the home’s referral assessment format. This will remind the assessor to cover all of the recommended best practice areas where this is relevant. Make arrangements for an experienced pharmacist to review the home’s medication practices, policies and procedures. Carry out a ‘lone working’ risk assessment taking account of the latest guidance issued by the Health and Safety Executive. 2. 3. YA20 YA42 Jubilee Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Mews DS0000000422.V338118.R01.S.doc Version 5.2 Page 34 - 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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