Inspection on 01/02/07 for Jubilee Villa

This inspection was carried out on 1st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Jubilee Villa 27/11/07

Jubilee Villa 05/12/05

Jubilee Villa 19/08/05

Jubilee Villa 24/08/04

Jubilee Villa 06/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Jubilee Villa Astley Shrewsbury Shropshire SY4 4BU Lead Inspector Joy Hoelzel Key Unannounced Inspection 09:55 1st February 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee Villa Address Astley Shrewsbury Shropshire SY4 4BU 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) 01939 210461 NONE Mrs Susan Mary Hartley Ms Margaret Lesley Read Mrs Susan Mary Hartley Ms Margaret Lesley Read Care Home 17 Category(ies) of Dementia (10), Mental disorder, excluding registration, with number learning disability or dementia (3), Old age, not of places falling within any other category (4) Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Jubilee Villa is a home providing accommodation and personal care for seventeen people. It is registered for the care of older people with dementia and mental illness. It is situated on a rural site near to the village of Astley just to the north of Shrewsbury and is privately owned. The house itself is a large converted and extended property and has pleasant views across the adjacent fields. There are a mixture of single and double occupancy bedrooms, together with communal sitting and dining areas. The gardens are well maintained and provide a secure and safe area for service users to enjoy. Fees for the service are currently at £364.60 per week. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. Commission for Social Care Inspection Reports for this service are available from the provider or can be obtained from www.csci.org.uk Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection is the first of the statutory inspections for 2006/07 and took place over five and a half hours on Thursday 1st February 2007. It was conducted by one regulation inspector. Twenty six of the thirty eight National Minimum Standards for older people were inspected on this occasion. Seventeen people are currently living at the home, staffing numbers were observed to be at the previous levels of three care staff with additional catering and domestic staff. Four case files were selected for case tracking, relevant documents and procedures were inspected, together with two randomly selected staff personnel files. Discussions were held with the manager, staff, service users and visitors during the day. A full tour of the premises was conducted. A pre inspection questionnaire has been completed by the manager and returned to the Shrewsbury Commission for Social Care Inspection office prior to this inspection. Eight relative/visitor comment cards and fifteen service users comment cards have been completed; the findings and comments will be included in this report. What the service does well: Information on the provision of the service is readily available, current and written in plain language. Full assessments of persons needs are undertaken prior to offering a placement at the home. This ensures that the care needs of the individual can be fully met. The staff demonstrated a good in-depth knowledge of the service user group and the conditions and dilemmas associated with the ageing process. The manager is highly aware of equality and diversity and its implications even when there are few people in residence with recognised diversity issues in receipt of the service. Social, leisure and recreational activities are arranged on a regular basis, based on the requirements of the service users and are age appropriate. Visitors and relatives commented ‘ a very good homely place ….a home from home’, ‘satisfied with the care provided’, Service users stated that they are ‘very well looked after’, ‘have no complaints’, ‘very happy to be here’. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their care needs assessed before moving into the home and when ever possible have the opportunity to visit the home to assess its quality, facilities and ability to meet an individual’s needs prior to admission EVIDENCE: Four case files selected for inspection including the files of two people recently admitted to the home. All four files contained pre admission information from the local primary care trusts, social services departments or local authorities. The two people most recently admitted had received an assessment of their care needs by the manager of the home prior to them moving in. One in particular was very concise and comprehensive and gave full details of all activities of daily living, recent social and medical history. The introductory Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 9 visits to Jubilee Villa were documented together with dates of conversations held with the next of kin. An initial plan of care was generated at the point of admission based on the assessments in one of the two people recently admitted, the other care plan documentation had not been completed. The manager stated that usually the care plan is developed during the first month of the persons stay. A family member confirmed that a visit was made to the home prior to making the decision to move in, and in their opinion it was the correct placement for their relative and were very satisfied with the care offered. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has a care plan. The plan in most cases includes the basic information necessary to plan the individuals care, some omissions of recording information has the potential for not fully meeting a persons needs. EVIDENCE: Four case files were randomly selected for inspection, the initial care plans are developed and based on the activities of daily living using a tick box approach, with the occasional brief details of any intervention’s documented where a care need has been identified. Specific care plans are then developed for certain areas of identified care needs; in all four care plans the development of the specific plans was irregular and inconsistent. For example there was no specific plan for personal or oral hygiene, mental health history, physical care and well being and medication although the core plan identified a need in this area as the boxes were ticked. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 11 Not all information is being detailed in the specific plans of care that have been developed, with important information being missed. For example a specific care plan for diabetes states ‘on insulin-BSM [blood sugar monitoring] daily’. There is no further instruction or information recorded as to the dosage of insulin, the optimum levels of blood sugar to be achieved, or what to do in the case of an emergency when unstable blood sugars have been monitored. Further in the case file an entry made in the daily report indicates a possible change to the levels of insulin needed due to unstable blood sugars being monitored, the report states ‘ take BM at Am and teatime before meals for one week then review with district nurse’. There is no written record of any follow up one week later. The manager and staff stated that this has been followed up with the GP with further monitoring required. The care plan was not reviewed and updated with this information. Another core care plan was ticked and identified needs in personal care and well being and medication. A specific care plan had been completed for swollen and bruising to right hand and wrist, the details have been documented with the care instructions from the GP. No other plan of care has been formulated. The daily report documented the intervention by the district nurse for a dressing on leg with ‘ leg redressed – much improved’. The pre admission assessment identifies a ‘small sore on back of left leg’ a care plan had not been developed for this. Another core care plan had been fully completed giving full details and instructions for staff to follow. A specific care plan has been developed for ‘unwitnessed falls and problematic behaviours’. This contained clear instructions for staff to reduce the risk of this person falling and the action to be taken if challenging behaviour is noted, the review date was documented together with an identified date of the next review. A specific care plan had been developed for ‘pressure area to sacrum’ and details the care implementation as ‘ bed rest to sit up in wheelchair for meals only’. There were no other details of the action needed to be taken by staff to reduce the risk of the development of further pressure areas, e.g. no information as to what equipment to be used on the bed or wheelchair, or the regular interventions needed by staff in relation to personal care whilst on bed rest. The dietary profile indicates of a low body weight with recent weight loss and instructs of ‘a pureed diet with 2 additional high energy drinks twice a day’. No record is maintained of the food offered or taken on a daily basis. The manager explained that the drinks supplements are not being offered regularly due to difficulties with obtaining a prescription from the GP but confirmed that currently this person is taking a good diet. The weight chart states ‘unable to weigh 12/12/06’. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 12 No comprehensive assessments had been completed for nutrition, risk of falls, moving and handling, tissue viability or the use of bedrails. The home operates a 28 day prescribing system for the administration of medication using the blister pack type with the additional use of bottles and boxes. The Medication Administration Record (MAR) charts appear to be correctly completed at the time of the administration, the receipt of medication to the home is checked in by two staff and recorded on the MAR. Some hand written entries have been made in the MAR where there have been changes to the medication, but have no signature or countersignature for the person transcribing the alterations from the prescribing label and Latin abbreviations have been used i.e. TDS written instead of three times a day. Protocols are not available to instruct staff when and how often to administer the ‘as required’ medications. This was discussed with the senior care staff allocated the responsibility of overseeing the medication procedures. During the tour of the premises a tube of cavilon cream was on the bedside locker of one person but had the name of a different service user hand written on the outer package. A tube of Fucibet ointment was on the shelf by the wash hand basin there was no date of when the tube was opened on the package. There was no recording of fucibet cream in the care plan or the MAR chart the manager could not offer an explanation for the use of the ointment. The care staff were observed to be assisting service users with personal care discreetly and in a manner which promotes a persons dignity. Staff, service users and visitors were observed to be interacting well with lots of chatter and conversation occurring. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of the home are planned around the service users needs and wishes. Staff listen to service users and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. EVIDENCE: During the morning of the inspection an exercise class had been arranged for the people in the sitting room. Eleven service users and two staff members were participating and appeared to be enjoying the activity. Staff were observed to be encouraging and supporting the people with the gentle exercises. Card games were arranged for the afternoon with people playing the higher or lower game. One service user was being assisted to use a laptop to write a letter to a relative. She had previously been a typist and appeared to be enjoying this. Good interactions were observed during the day between service users, staff and visitors. One visitor stated that they visit very regularly and always found Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 14 the staff pleasant and helpful and that the family were very satisfied with the care provided to their relative. A daily programme of activities is arranged through out the week. The service user guide includes information on social and leisure activities, arrangements to attend religious services and for maintaining the contact with relatives, friends and representatives. Eight people indicated in the service users comments cards that the home arranges activities that they can take part in, two people indicated that activities are not arranged and one person made an additional comment of ‘I don’t like joining in’. One person made an additional comment in the relative/visitor comment card of ‘ more activities and social events now’. During the tour of the premises many of the bedrooms were highly individualised with personal possessions. Staff were observed to be offering service users choices and preferences as to the activities of the day in an appropriate way, very much dependent on the capabilities and capacity of each individual. The manager stated that visitors are able to see service users in private if they so wish with the use of the private bedrooms. An additional comment received by a relative on the comments cards indicated ‘ ……for a comfortable place to sit, with some measure of privacy…. I feel residents and visitors would benefit from this’. Staff commented that breakfast is usually served in the main dining room but could be taken in the bedrooms if required. The dining tables were prepared for lunch with most service users being served their meals at the table. The meal appeared to be well cooked and balanced. Service users appearing to enjoy it. Eleven of the fifteen people completing the service users comment card indicated that they liked the meals at the home, two people made additional comments of ‘no complaints’, ‘food is excellent’. Visitors to the home stated they had no complaints with the food offered and observed it to be ‘ good and well cooked’. The Environmental Health Officer visited and inspected the premises in March 2006, some recommendations were made, and the manager confirmed that arrangements had been made to fully comply with the recommendations. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally and robust procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The complaints procedure is included in the service user guide and a copy is displayed at the entrance of the home. One complaint was made directly to the home by a relative of a service user, this was fully documented with the outcome of the investigation and the manager stated that the family were satisfied with the explanation and outcomes. Seven out of the fifteen people who completed the service users comment card indicated that they knew how to make a complaint should they wish to do so. All eight relatives/visitors comment cards completed and returned indicated that they were aware of the complaints procedure only one person indicated that they had raised concerns directly with the home. The Commission for Social Care Inspection have not received any complaints /concerns directly during the period of time since the last inspection. No referrals have been to the vulnerable adults team. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 16 A copy of the multi agency adult protection procedures are available for staff reference if required, the manager stated that some staff have received training in protection of vulnerable adults. Procedures are in place for the safekeeping of service users monies should they so wish. Individual accounting records are maintained for each transaction with the service users signature being obtained whenever possible. On checking, the balance on one sheet and the amount of actual cash held, accurately corresponded. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provides a homely environment and will benefit from some redecoration and refurbishment. There are one or two areas that pose a potential risk to service users, for example, some bedrails are not fitted correctly and water may be very hot coming from a tap due to a lack of a safety valve. EVIDENCE: The home does not have a programme of routine maintenance and renewal of the fabric and fittings. The manager stated that work is carried out on an ‘as required’ basis. The local Fire Officer visited and inspected the premises in January 2007 and made some recommendations to improve the safety aspects in some areas of the home. The manager confirmed that contractors have been contacted for Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 18 the work to be carried out to ensure full compliance with the fire officer’s recommendations. During the tour of the premises some areas are in need of redecoration and are looking ‘tired’, some carpets and furniture would benefit from being replaced. The manager stated that the first floor bathroom is never used and that all service users use the bathroom on the ground floor but states that this is in need of refurbishment. Mixtures of commodes, wooden/metal, were in most bedrooms for use during the night. It is difficult for wooden commodes to be thoroughly cleaned and as such pose a risk for maintaining hygiene and the effective control of infections. The manager discussed the procedures in place for disposing of bodily waste. The installation of sluicing disinfectors was discussed with the manager to ensure the safe disposal of bodily waste, to enhance the working conditions for staff and reducing the risk of contamination, splash back accidents and cross infection. It appeared during the tour of the premises that one bedroom had not been provided with a lockable storage space for money or valuables but all bedrooms doors have been fitted with a lock. The manager explained that the majority of service users do not hold a key to their bedroom door. One service user explained that she preferred to lock her door when she was out of the bedroom; staff had provided her with a key and suitable chain for the safekeeping of the key. The bed rails in use were not fitted correctly; risk assessments or regular safety checks have not been carried out. Unsuitable bed rails (child type) were taken out of use immediately. The hot water outlets accessible to service users have not had a fail safe valve fitted and random testing of the hot water in service users bedrooms recorded a temperature of 60 degrees Celsius. The bathroom had a low hot water temperature of around 39 degrees Celsius. The manager confirmed that the contractor would be contacted and all hot water outlets would be fitted with safety valves to ensure that the temperature at all outlets accessible to service users is maintained at around 43 degrees Celsius. It was discussed with the manager the need for risk assessments to be carried out, to reduce the risk of scalding to service users who are able to use the wash hand basins in their bedrooms independently. Communal toilets, bathroom and private bedrooms had been supplied with cloth hand towels; paper towels, liquid soap and a lidded disposal bin must be provided for the effective control of infections in all communal areas and at the point of the delivery of care. Twelve people indicated in the service users comments cards that the home is always fresh and clean. One person indicated in the relatives/visitors comments cards ‘ very satisfied with the care and accommodation’. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good recruitment procedure that is followed in practice, which ensures the delivery of good quality services and for the protection of service users. The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for service users. EVIDENCE: A rota is maintained to show which staff are on duty at any given time of the day or night. At the time of the inspection three care staff were on the premises with one being the senior carer and in charge of the premises, catering and domestic staff are additional. The manager works in a supernumery capacity five days per week. Two staff personnel files were selected for inspection and contain all documents relating to a robust recruitment procedure. The provider must ensure robust recording of all decision making throughout the processes of recruitment and employment Certificates and records of achievement are retained to evidence the training undertaken by each individual. Each staff member has regular supervision with their line manager and an annual appraisal of their work performance. Training and development needs are identified and arranged throughout the year. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 20 All senior staff and some care staff have attended courses at a local College for dementia awareness. The manager explained the difficulties with obtaining food hygiene training courses within the area and has obtained a video for staff to use while training opportunities are being pursued. Indications from the service users comments cards regarding staff availability are that five people feel there is always staff available when they need them, five felt that usually there are staff available, three indicating only sometimes and one person feeling there is never the staff available. Five of the seven relative/visitors comments cards indicated that in their opinion there were always sufficient staff on duty, one person indicated ‘mostly’ with one person feeling that there is not enough staff. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are very clear lines of accountability within the management structure and the management approach creates an open and positive atmosphere from which the service users benefit. EVIDENCE: The manager is a first level nurse with the skills and experience to run the home. Throughout the duration of the inspection the manager demonstrated a good knowledge of the current service user group and the difficulties and dilemmas encountered with the ageing process. Staff, service users and visitors spoke very highly of the manager and the management systems and stated that they would have no hesitation but to speak with the manager should they have any concerns or worries. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 22 Three people made an additional comment on the relative/visitor comment card of ‘ very friendly home … it feels like a family…. everyone knows each other’, ‘ home from home’, ‘ Jubilee Villas’ atmosphere is warm, loving and caring…comfortable surroundings…staff try so hard to take care of the residents and deal with individual needs’. Quality assurance and monitoring systems continue with weekly and monthly audits conducted. Satisfaction surveys have recently been sent to service users, families, and staff and are used as a monitoring tool. A report on the findings of the surveys sent in 2005/06 had been prepared and used as a tool for improving the service provision. Procedures are in place for the safekeeping of service users monies should they so wish. Individual accounting records are maintained for each transaction with the service users signature being obtained whenever possible. The balance on one sheet and the amount of actual cash held accurately corresponded. Weekly and monthly safety monitoring continue to be carried out e.g. fire alarm, emergency lighting etc. Testing for legionella has been conducted the manager stated that the report is due from the contractors. All equipment in use (bedrails, wheel chairs etc) must be monitored on a regular basis to ensure that they are fit for the purpose, safe and in good repair. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 2 X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 15(1) Requirement The registered person must ensure that care plans are developed for the identified care needs. The plan must detail the action needed to be taken by staff to ensure that all aspects of the health, personal and social care needs are fully met. The registered person must ensure that the care plans are updated and reviewed when a change in need has been identified. The registered person must ensure that risk and monitoring assessments are carried out, their findings recorded and where necessary linked with a specific plan of care. The registered person must ensure that all handwritten instructions on the Medication Administration Record charts mirror the prescribing instructions and signed by two people. The registered person must ensure that medication is administered only to whom the DS0000020708.V326981.R01.S.doc Timescale for action 31/03/07 2 OP7 15(1) 31/03/07 3 OP8 12(1) 31/03/07 4 OP9 13(2) 31/03/07 5 OP9 13(2) 31/03/07 Jubilee Villa Version 5.2 Page 25 6 OP21 23(2)(j) 7 OP22 16(2)(c) 8 OP25 13(4)(a) (c) 9 OP26 13(3) 10 OP38 13(4)(a)( b)(c) medication is prescribed for. The registered person must ensure that the home has sufficient bathrooms in use suitable for the needs of service users The registered person must ensure that all equipment (commodes, bed rails etc) are fit for the purpose and suitable for meeting the assessed needs of service users. The registered person must ensure that all hot water outlets accessible to service users are fitted with a failsafe valve to maintain a temperature at around 43 degrees Celsius. The registered person must ensure that paper towels, liquid soap and a lidded disposal bin are provided in all toilets and bathrooms and in all areas at the point of the delivery of care. The registered person must ensure that risk assessments are carried out for all safe working practices and that the findings of the assessment are recorded. 30/06/07 31/03/07 30/06/07 31/03/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended that all external medications are dated upon opening with tubs of creams/ointments discarded after one month of opening and tubes after 3 months of opening. It is strongly recommended the home develop and maintain an ongoing redecoration/refurbishment plan. It is strongly recommended that consideration be given to DS0000020708.V326981.R01.S.doc Version 5.2 Page 26 2 3 OP19 OP26 Jubilee Villa the installation of automatic sluicing disinfectors, on each floor, for the safe disposal of bodily waste. Jubilee Villa DS0000020708.V326981.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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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