CARE HOMES FOR OLDER PEOPLE
Jubilee Nursing Home Thornhill Crescent Sunderland SR2 7AD Lead Inspector
Sharon McDowell Announced Wednesday 31 August 2005 at 9:00am
st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Jubilee Nursing Home Address Thornhill Crescent Sunderland SR2 7AD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 565 2727 0191 565 4737 Ms A Marsden Mrs C Trueman Care Home 40 Category(ies) of OP Old age - 40 registration, with number PD (E) Physical disability over 65 - 4 of places TI Terminally ill - 4 PD Physical disability - 1 Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 30th March 2005 Brief Description of the Service: Jubilee Care Home is a purpose built three-storey building, which can provide nursing and personal care for up to 40 older people. It is of traditional brick build design and has an ample size car park to the rear of the building. There are large lounges, a separate smoking lounge and a dining room on the ground floor with bedrooms on the first and second floors. On the ground floor there is a pleasant conservatory at the front of the building, which has level access into the garden area. The Home offers both single and double bedrooms, with the majority having en-suite facilities. The Home is very close to the city centre of Sunderland and benefits from being near the shopping centre, library and the transport network. There is a large park close to the Home as well as local tourist attractions Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place over six hours during which time the inspector met with six residents, four visitors, two staff, the Registered Manager and Area Manager. As this was an announced inspection the Registered Manager had submitted a pre-inspection questionnaire with information about such matters as, staffing numbers, staff training, company policies, dependencies of the residents and complaints. As part of the inspection the inspector sat with three residents and shared lunch with them. A tour of the building was also carried out to look at any environmental, equipment, furniture and fitments issues. The Commission for Social Care Inspection did not receive any comment cards from residents or visitors. What the service does well: What has improved since the last inspection?
The residents have now got a phone that they can use privately. Although they were able to use the office phone this was not the best arrangement and now there is a mobile pay phone they can take to a phone point either in their bedrooms or in a quiet area of the Home. Some areas of the Home that needed redecoration have now been done or there are plans to carry out work, for example, tidying up tiling in the bathrooms. The Home has a decoration programme that tries to makes sure resident’s bedrooms are decorated before they move in to the Home.
Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 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. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The Home has sufficient information to be able to make a judgement as to whether they can meet the assessed needs of prospective residents. EVIDENCE: Care plans provide evidence that a full needs assessment is provided by a Care Manager or Nurse Assessor prior to a resident coming to live in the Home. The assessment includes information, such as, nutritional needs, moving and handling, risk assessments and social care needs. The Registered Provider has an assessment form that is used to confirm the residents care needs. A member of staff would usually visit the prospective resident to carry out the assessment before they come to live at the Home. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 10 Care plans are generally completed with sufficient information to guide staff in how to care for individual residents. However, not all aspects of health and social care are documented, which means some aspects of care might not be met. Staff at the Home treat residents support residents in a respectful manner, which promotes their right to a dignified life. EVIDENCE: All residents have an individual care plan, which contains information about their care requirements based on an assessment of need. Most of the care plans were completed adequately for staff to be able to give care to the resident. Some discussion took place about how social history information is gathered. A good life history document is available, which initially the Registered Manager stated the activity person completed by asking the resident questions from the document. During lunch a resident was able to recount their war time experiences in some detail however little was recorded in their care record except for a statement that the resident had become upset when answering the questions. This might not have occurred if the
Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 10 information was gathered in a more informal manner and also if all staff contributed as they gained information about a resident. One care plan did not correspond with the Nurse Assessors assessment in relation to pain and analgesia requirements, which might mean the residents pain relief is not attended to and controlled. A telephone is available for the residents to use on a personal basis. It is available to be used in resident’s bedrooms so they are able to have private conversations. Residents and relatives stated they were treated in a friendly and respectful manner when they came into the Home. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 13 Residents are offered the opportunity to participate in a range of social activities encouraging them to lead fulfilled lives. Visitors are welcomed to the Home therefore residents can be assured they will be able to keep in touch with their families and friends. EVIDENCE: There are several displays of photographs around the Home showing residents participating in social activities. Some events have included St Georges Day celebrations with the red, white and blue theme throughout including cakes decorated in the union colours. Some of the residents said they particularly enjoyed an entertainer who made shapes from balloons and also sang for them. The summer fete successfully helped to raise money for the residents social fund, which is used to help pay for social events. The Registered Manager also stated that the Registered Provider is good in providing a generous budget for provision of activities. Records of the activities that residents have participated in are kept in their individual care plans, which are completed by the activity organiser who also completes the social biography of resident’s lives. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 12 On the day of inspection an entertainer was programmed for the afternoon. Residents and their relatives were seen to be enjoying his singing, especially of the songs from their era. Visitors were seen coming and going to the Home throughout the day. Many of them commented on their satisfaction with the care and services provided in the Home. They appreciated the Home being so close to the town, which made it easier for transport. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 A clear complaints procedure is available but records of complaints are not adequately maintained to enable review of the process to ensure complaints are managed in a fair and robust manner. Adult protection training, policies and procedures are in place therefore contributing to the protection of residents from harm. EVIDENCE: Since the previous inspection the Registered Manager has received one complaint. There were no records of the complaints investigation or information about whether the complainant was satisfied with the outcome of the investigation and the copy letter that was sent to the complainant with the outcome of the investigation was not dated, which means it is difficult to review whether the complaint was investigated appropriately and thoroughly. The Registered Providers policy for complaints is available in the Home for staff reference and all complaints are supposed to be forwarded to head office for review by the relevant area manager. Complaints forms are available around the Home for residents or visitors to pick up if they wish to make a complaint. A high proportion of staff have attended training in Protection of Vulnerable Adults, which means staff know what is classed as abuse and what to do if they should come across abuse of a resident. Local Protection of Vulnerable Adults policies and procedures are available alongside those of the Registered Provider so that staff have a reference tool to use if they need to. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Nil None of these standards were reviewed at this inspection therefore will be reviewed at the next inspection. EVIDENCE: Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The staff recruitment procedure is operated in a robust manner therefore safeguarding the residents from potential harm. EVIDENCE: Personnel files for staff employed at the Home contain evidence such as application for employment forms, Criminal Record Bureau clearance and two references, which is needed to make sure the right people are employed at the Home. Following the previous inspection the Registered Provider has mow implemented standard interview questions, which ensures equality when people are being interviewed for a job. There is a clear recruitment policy available in the Home for the Registered Manager and staff to refer to for guidance. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The Home is reasonably well maintained and staff trained to ensure the health and safety of residents is promoted. EVIDENCE: The home employs a maintenance man who is responsible for day-to-day repairs and monitoring of equipment and amenities in the Home. He keeps a file with all records of checks he has made and certificates of servicing by external companies, such as gas, electric and fire authorities. The preinspection questionnaire confirms that all services have been maintained at the required intervals. Some discussion took place about how best to record that staff have attended the required number of fire safety training sessions. There is a matrix of training in place, which one of the registered nurse’s maintains. This makes it easy to see what training staff have attended. She also has a plan of training in place to enable so that she will ensure all staff will attend mandatory
Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 17 training. A range of training has been provided including, food hygiene, health and safety, first aid and moving and handling. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x x x x x x 3 Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 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. 1. Standard OP7 Regulation 12,14 & 15 Requirement Residents care plans must be reflect their assessed needs and be completed in sufficient detail to make sure staff have up to date guidence about care required by the resident. Complaints records must be maintained in sufficient detail to provide evidence of investigation and responses with the complainant. Timescale for action 30/11/05 2. OP16 17 31/8/05 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 OP38 Good Practice Recommendations fire training records should be amended to show staff have attended the required number of training sessions. Jubilee Nursing Home B52-B02 S18198 Jubilee V213299 310805 stage 2.doc Version 1.40 Page 20 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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