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We are carrying out a review of quality at Jabulani. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Inadequate

Updated 4 October 2019

About the service

Jabulani is a residential care home providing accommodation and personal care for people with learning disabilities, physical disability and sensory impairment. The service is one adapted building with nine en-suite bathrooms, there is a lift which allows access between the ground and first floors.

The service is bigger than most domestic style properties. It was registered for the support of up to 11 people. Ten people were living there at the time of the inspection. This is larger than current best practice guidance.

The service did not apply the principles and values of Registering the Right Support and other best practice guidance. These were designed to ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

People’s experience of using this service and what we found

Practice at the service placed people at risk of avoidable harm. Bathing facilities were not fit for purpose to safely meet the needs of some of the people living there. The physical environment was not decorated or adapted to a consistent standard to meet the needs of people living with physical disability.

Risks to people’s safety were not always assessed, mitigated or managed. Risk assessments weren’t always in place. Some risk assessments were old and had not been reviewed in line with people’s changing needs.

The provider did not have a credible statement of vision and values. Roles, responsibilities and accountability arrangements were not clear. There were a lack of governance and auditing systems and processes.

Medicine documentation was not always clear. Some people’s medicine administration records were missing or out of date.

There was limited use of systems to record and report safety concerns, near misses, accidents or incidents.

Safeguarding referrals were not always given sufficient priority. Some incidents had not been referred to the local authority safeguarding team.

There were enough staff, however they were not always deployed effectively to safely carry out their role. For example, there were no team leaders on night shifts which meant staff needed to call an on-call member of staff if someone required medicine administration.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The physical environment was not decorated or adapted to a consistent standard to meet the needs of people living with physical disability.

People’s privacy and dignity were not always respected. There was a lack of systems to identify and therefore protect people against lack of privacy and dignity.

People were not always supported to express their views about their own care. There were times when this had been done in a way that the person was unable to engage with.

People’s equal and diverse needs and preferences were not always documented or explored. Although people were not discouraged from expressing their individuality.

Care planning was not robust enough to empower staff to ensure people had choice and control.

Information was not always provided in a way that people could understand.

Staff were kind and caring, we saw pleasant interactions and that people appeared to enjoy the company of the staff during the inspection.

Infection prevention and control procedures were in place and the home was clean and free from malodours.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published June 2018)

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels, documentation, staff training and managerial support provided to staff. A decision was made for us to inspect a

Inspection areas

Safe

Inadequate

Updated 4 October 2019

The service was not safe.

Details are in our safe findings below.

Effective

Requires improvement

Updated 4 October 2019

The service was not always effective.

Details are in our effective findings below.

Caring

Requires improvement

Updated 4 October 2019

The service was not always caring.

Details are in our caring findings below.

Responsive

Requires improvement

Updated 4 October 2019

The service was not always responsive.

Details are in our responsive findings below.

Well-led

Inadequate

Updated 4 October 2019

The service was not well-led.

Details are in our well-led findings below.