Care Home: Jubilee Lodge

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What the care home does well People who use the service told us they felt there was a ‘pretty relaxed’ atmosphere in the home. They also told us they felt they had ‘really improved’ since they moved in and that they ‘feel like they are helping me’. Individuals told us that this service was ‘much better’ than places they had stayed at in the past. People felt that they were moving towards a more independent lifestyle. People who use the service are well informed and have a clear understanding of any limitations placed on their personal freedom and have worked with staff to set up their own terms or conditions for continuing to live at the home. Staff have worked well to develop good relationships with people who use the service. Discussions with staff and individuals who use the service indicated that the importance of maintaining and developing family links was acknowledged within the service. The pre admission assessments carried out by the service provide very good information for staff to develop initial care and action plans. People who use the service and staff have worked well to set up social networks and activities in a relatively short period of time. Individuals we spoke to were pleased with their progress in attending further education classes.Jubilee LodgeDS0000073055.V376520.R01.S.docVersion 5.2 What has improved since the last inspection? This is the first inspection of Jubilee Lodge. What the care home could do better: To ensure the safety of people who use the service the organisation must have a complete employment history for each member of staff before they start work in the service. This record must also include satisfactory explanations for any gaps in employment. To ensure the safe management of medication all staff who administer medication must be provided with accredited training. The medication administration record must include all medication administered and the record of medication needs to be further developed. To ensure the safety of people using the service bathrooms and toilets need to be fitted with locks which can be opened from the outside in the event of an emergency. To provide people who use the service with a more homely environment lampshades should be provided for all ceiling lights. Care planning should be further developed to include more details of how the needs of individuals will be met, clear goals and areas of responsibilities. Where changes have occurred the care planning and action plans need to be up dated. Key inspection report CARE HOME ADULTS 18-65 Jubilee Lodge Jubilee Lodge 3 Hartherleigh Close Morden Surrey SM4 5AD Lead Inspector Liz O`Reilly Key Unannounced Inspection 24th June 2009 10:00 Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jubilee Lodge Address Jubilee Lodge 3 Hartherleigh Close Morden Surrey SM4 5AD 020 8545 0030 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) Supreme Care Services Limited Majekodunmi Omosanya Otubanjo Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 3 18th June 2009 Date of last inspection Brief Description of the Service: Jubilee Lodge is a registered care home providing accommodation and care for up to three adults with mental health needs. The building is a domestic property with two bedrooms on the first floor and one on the ground floor. A kitchen, dining room and lounge are available on the ground floor. The service is situated in a residential area of Morden, close to transport, entertainment and shopping facilities. Current fees are from £750 per week. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection was carried out on 24th June 2009 by one Regulation Inspector. At the time of this visit two people were living in Jubilee Lodge. The inspector had discussions with the people using the service and the service manager. A sample of the records kept were looked at. The manager sent to the Care Quality Commission (CQC) their own assessment of the service (AQAA) which set out what has been achieved since the service opened and plans for future improvements. This is the first inspection of this service since it was first registered with the CQC. What the service does well: People who use the service told us they felt there was a ‘pretty relaxed’ atmosphere in the home. They also told us they felt they had ‘really improved’ since they moved in and that they ‘feel like they are helping me’. Individuals told us that this service was ‘much better’ than places they had stayed at in the past. People felt that they were moving towards a more independent lifestyle. People who use the service are well informed and have a clear understanding of any limitations placed on their personal freedom and have worked with staff to set up their own terms or conditions for continuing to live at the home. Staff have worked well to develop good relationships with people who use the service. Discussions with staff and individuals who use the service indicated that the importance of maintaining and developing family links was acknowledged within the service. The pre admission assessments carried out by the service provide very good information for staff to develop initial care and action plans. People who use the service and staff have worked well to set up social networks and activities in a relatively short period of time. Individuals we spoke to were pleased with their progress in attending further education classes. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service understands the importance of having sufficient information when choosing a care home. Detailed assessments are carried out for each person before they move into the service to ensure that their individual needs and aspirations can be met. EVIDENCE: People who use the service told us they would grade the home as ‘excellent’ and ‘good’. Each person is provided with a Service User Guide which gives information on what they can expect from the service. We were provided with a copy of this document. The details for contacting the Care Quality Commission require updating. In the section on complaints an addition should be made to inform people that they can approach the placing authority at any time should they have any concerns. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 9 The manager informed us, through their assessment of the service (AQAA), that a full assessment is carried out before anyone is admitted to the home. We looked at the assessments carried out for each person and found the assessments to be detailed and of good quality. The service also receives copies of assessments carried out by the placing authorities. This information is used to make sure that the service can meet the needs of each individual and provides good information for staff to have some understanding of the individual from day one. Care should be taken to ensure that staff sign and date all documents including pre admission assessments. The manager told us that the admission process is carried out over a period of time to allow individuals to try the service before moving in. Individuals visit for one day and a weekend and then move in on a three month trial basis. People who use the service told us they had visited the service on a number of occasions before they made the decision to move in. One person told us they chose their bedroom during these visits. Individuals confirmed members of their family were also involved in their admission. The manager informed us that he will be consulting with the people who are living at the service when making decisions about another person moving in and will be looking at the needs of the group as well as any new person. The two people who are using the service have signed a general conditions of residency agreement which includes respecting each other and property. A more specific agreement regarding certain areas such as visitors, food and staff access to their bedrooms has also be agreed and signed. Other professionals were involved in setting up this agreement. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is developing person centred care planning. Individuals are involved in the planning of the support they receive. Risk assessments are carried out and reviewed for each person to ensure that individuals receive the right levels of support. Any limitations on individuals are discussed with the person concerned. EVIDENCE: Each person who uses the service is provided with a care plan and a Wellness Recovery Action Plan (WRAP). These documents set out individual needs, objectives and actions. We looked at these records for the people living at the service. A wide range of issues are covered, including individual mental and physical health, activities of daily living, medication compliance, community and social inclusion and engagement with other professionals. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 11 People who use the service told us they were involved in setting up their individual Wellness Recovery Action Plan. These were seen to be written or dictated by and signed by them. Staff carry out a monthly review for each person which was seen to record activities and any progress made. People who use the service are allocated a key worker. Individuals we spoke to were happy with their present key worker and felt they were well supported by these staff. Each person meets with their key worker each month to discuss plans for the future and any concerns they may have. These meetings were seen to be recorded and people who use the service are given the choice of where to have these meetings, in the service or in the community. Staff have made a good start in setting up care planning documents. However the planning could be expanded to be more person centred. Information around personal goals and targets along with how these will be met could be expanded. Consideration should be given to setting clear timescales and allocating responsibility within the staff group for assessing the progress made in meeting targets or goals. Although staff are carrying out monthly reviews which show individuals are making progress this is not reflected in the care planning or WRAP documentation. These care documents should be updated when changes occur or targets are met. Consideration could be given to completing WRAP documents over a longer period of time to allow people to set more targets or goals once they have settled into the home. We saw that risk assessments are in place for individuals. These were seen to be set up using initial information from pre admission assessments and discharge information. Staff were seen to be up dating these documents which ensures the individuals receive the right levels of support. Risk assessments were seen to be shared with the individual concerned. Staff were seen to be keeping good, detailed daily records which include information on activities during each day along with information on the general well being of individuals. A daily report is completed for each person which covers a wide range of issues including risks. This document is used at staff handover and assists in ensuring good communication within the staff group. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service take part in a variety of activities in the local community. Good progress has been made in taking up college placements with a view to re entering employment. The service understands the importance of maintaining or re establishing family contacts. People who use the service enjoy the food provided. EVIDENCE: Individuals who use this service told us that staff were ‘good at teaching independence’. They said that they can ‘mostly’ do what they want each day. Both of the people using the service have started further education courses at a local college since they moved in with a view to getting back to employment. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 13 People take part in a variety of activities including attending social events at a local family centre, Art classes, women’s groups, shopping, walks, meals out and attending a local gym. Agreement has been reached with other professionals for one person to seek voluntary work. People who use the service told us that they enjoyed various activities and were particularly pleased with the progress they had made through attending college. Although certain restrictions are placed on the individuals using the service they had a clear understanding of what these restrictions were and why they were in place. As noted previously each person has signed their own agreement with the service. Staff have worked with individuals who have broken part of these agreements which could have resulted in a disruption of the placement. People who use the service told us they enjoy the meals provided. The service keeps a record of the meals which showed a good variety of food. Staff were seen to give advice on healthy eating. People using the service decide with staff what they are going prepare. One person told us they ‘mostly make their own meals’ and the other person told us ‘we cook for ourselves or help to make the meal’ staff are available to assist and support individuals with cooking. People who use the service go food shopping with staff on a regular basis. The manager informed us that the service works to encourage family contacts. Family members visit the home, take their relative out for a meal and individuals will go to visit them. One person who uses the service told us they were looking forward to taking a holiday with their family in the near future. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The healthcare needs of individuals using the service are met. Medication is adequately managed but staff need further training in this area. EVIDENCE: Each person using the service is registered with a local GP practice. Individuals told us they could see their GP in private or with support if they wished. Staff informed us that they have good relationships with the community psychiatric services who will visit the service periodically. Reviews are carried out by the psychiatric services on a regular basis. Individuals have attended meetings in the community to provide support in dealing with particular issues Staff informed us that they monitor the physical and mental health of individuals and this was reflected in the records we saw. People are supported to attend health care check ups. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 15 We looked at the record of medication kept by staff. Medication administration records were mostly up to date. However one item of medication was not entered on the record. In addition the records could not provide information on how much medication was in the service at any one time. This was discussed with the manager. Staff have received training on the administration of medication. However this was not at the level of accredited medication training. Risk assessments were seen to have been carried out with regard to individuals administering their own medication. This resulted in the request to self medicate being turned down. The risk assessment was seen to have been signed by the person using the service which ensures that they have a clear understanding of why this has not been agreed at this time. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a complaints procedure in place with systems for the recording actions taken. Staff are provided with training on safeguarding people. EVIDENCE: People who use the service told us they were aware of who they could speak to if they had any complaints or concerns. People who are new to the service are provided with a Service User Guide which includes information on how to make a complaint. We looked at the complaints information provided in the Service User Guide. This gave good information on how complaints would be dealt with by the organisation. However the information on how to contact the Care Quality Commission needs to be updated. Information should also be added to let individuals know they can approach the placing authority at any time should they have any concerns. Staff should make sure that the contact details of their placing authority are provided to each person. At the time of this inspection one person was being assisted to manage their budget. Small amounts of money were held in the service for this person. Staff were seen to be keeping records of any money brought in and spent. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 17 Staff have been provided with training through a local authority on safeguarding individuals. Records showed that staff have taken prompt action where individuals using the service have placed themselves at risk. The organisation has also taken swift action where staff have not worked to the standards expected of them in the service. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service are provided with a comfortable domestic style environment which meets their needs. All areas of the service are clean and fresh. EVIDENCE: People who use the service told us they liked the environment. One person showed us their bedroom which was decorated to a good standard and comfortably furnished. Additional storage had been added at the persons’ request. One bedroom is on the ground floor with two on the first floor. Communal areas of a lounge, kitchen and conservatory are on the ground floor, with a garden to the rear of the house. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 19 The building was seen to be well maintained. We noted that none of the ceiling lights were fitted with lampshades. This should be addressed. To ensure the privacy of individuals along with their safety locks which can in an emergency be unlocked by staff from outside should be fitted to bathrooms and toilets. All areas of the service we saw during this inspection were clean and fresh. People who use the service told us they keep their own bedrooms clean and tidy and assist with the cleaning of the rest of the service. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were seen to be available to meet the needs of the people living at the service at the time of inspection. Staff are provided with good opportunities for training. Further work should be done to ensure that the training provided is at the appropriate level. The majority of records required in relation to staff recruitment were in place. EVIDENCE: People who use the service told us they got on well with individual staff members and were happy with their allocated key workers. We observed good, friendly and supportive interactions between staff and individuals using the service. A minimum of one member of staff was seen to be on duty in the service at all times. The deputy manager works between this service and another similar Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 21 service within a few minutes walk of Jubilee Lodge. We were informed that the majority of the deputy managers time was spent at Jubilee Lodge. One project worker also works between the two services. The staffing levels seen were not as those agreed when this service was registered. However the service is not fully occupied and the levels of support individuals require were not as high as envisaged when the service was being planned. People using the service told us they felt well supported and were not in any way restricted by the lower levels of staffing. The staffing levels will need to be reviewed on a regular basis as the number of people using the services increases and taking into consideration the needs of the individuals. The service does not use agency staff. Staff have been provided with training on safeguarding people, the Mental Capacity Act, deprivation of liberty legislation, mental health, challenging behaviour, medication and first aid. As noted previously further training needs to be provided on the management of medication. The manager should also ensure that sufficient staff have received training to an appropriate level to ensure a qualified first aider is available at all times. The manager informed us that plans were in place for staff to receive training on communication, person centred planning, activities and Schizophrenia in the near future. All staff are in the process of completing NVQ level two training. The deputy manager has completed NVQ level 3 and is in the process of completing NVQ level 4. One member of staff is working towards achieving a health care related degree. We looked at a sample of staff files. These showed the majority of the required checks were carried out before staff started to work in the home. This assists in safeguarding people who use the service. However a full employment history was not available on the files we looked at. This needs to be addressed. Records showed staff receive regular one to one supervision which assists in ensuring they are working in line with the service aims and objectives. Staff meetings are also recorded. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the skills and knowledge to run the service. Systems are in place to consult with people who use the service and others about how the service is performing. Regular checks are carried out to ensure the health and safety of people who use the service, staff and visitors. EVIDENCE: The manager has completed NVQ level 4 in care management and the Registered Managers Award. Jubilee Lodge and a second home are managed jointly. The second service is within a few minutes walking distance and so the manager can be called upon quickly if he is not in the home. We found the Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 23 manager had a comprehensive knowledge of the people using the service and we observed good supportive interactions between the manager and individuals. Regular meetings are held with people who use the service so that their views can be sought on the day to day running of the service. This was confirmed by people who use the service and we saw that minutes of the meetings are kept. The organisation has developed systems for monitoring the quality of the service which includes seeking the views of people who use the service and their relatives through surveys. Consideration could also be given to including feedback from other professionals and visitors to the service in this process. We saw a suggestion box was available in the entrance hall so that individuals can make comments on the service. We looked at a sample of the records kept in relation to the health and safety of people who use the service. We found these to be well maintained and up to date. Staff make weekly checks on the fire alarm system and regular fire drills are carried out which ensures that staff and people who live at the service have a clear understanding of what to do should the alarms be activated. A record of any problems with evacuation of the premises is kept. A record of any accident or incident is kept and reviewed by the manager. This assists in ensuring that risk assessments are kept up to date and actions are taken to minimise any future accidents or incidents where ever possible. Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 X Version 5.2 Page 25 Jubilee Lodge DS0000073055.V376520.R01.S.doc Are there any outstanding requirements from the last inspection? n/a STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement To ensure the health and welfare of people who use the service a record must be kept of all medication administered. To ensure the health and welfare of people who use the service any medication carried forward must be recorded along with medication received from and returned to the pharmacy. Timescale for action 01/09/09 2 YA20 13(2) 01/09/09 3 YA20 YA35 13(2) 18(1)(c ) To ensure the health and welfare 01/09/09 of people who use the service all staff who administer medication must be provided with training to an appropriate level. To ensure the safety and privacy of people who use the service locks, which can be opened by staff from outside in an emergency must be fitted to bathrooms and toilets. To assist in safeguarding people who use the service a full employment history, together with a satisfactory written explanation of any gaps in DS0000073055.V376520.R01.S.doc 4 YA24 23(2) 01/09/09 5 YA34 19 Schedule 2 (6) 01/09/09 Jubilee Lodge Version 5.2 Page 26 employment must be obtained for each member of staff before they commence work in the service. 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 2 Refer to Standard YA1 YA6 Good Practice Recommendations The Service User Guide should be updated with the current contact details for the Care Quality Commission. Care planning documents should be updated when changes have occurred such as goals or targets being achieved. More detailed information on how the service will be supporting people to meet targets or goals should be included in care planning documentation. Consideration should be given to allowing people who use the service more time to set their own goals. All ceiling lights should be fitted with lampshades. The manager should carry out a review of the training provided to make sure this provides staff with the appropriate levels of knowledge. First aid training should be provided to a level so that a qualified first aider is available at all times. 3 YA6 4 5 6 YA6 YA24 YA35 Jubilee Lodge DS0000073055.V376520.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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