Jubilee Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had cultivated a learning culture amongst the staff team, and learning was shared between services the provider ran. Staff told us mistakes and lessons learnt were “communicated openly and appropriately,” this helped, “ensure everyone learnt from the incident and prevents it from happening again.”

We saw evidence the management team reviewed incidents and accidents regularly and thorough investigations were carried out following incidents to establish the root cause and identify any areas for learning. Incidents involving falls and choking were analysed monthly to identify any trends.

The provider understood the duty of candour, to ensure they informed people and their relatives when things went wrong. A relative told us, “They do ring me up following any mishaps.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Professionals who worked alongside the home to complete pre-assessments, spoke positively about the smooth and safe transitions people experienced when moving into the home. They described good communication, “They will always complete these assessments in a timely manner. If they ever have any queries with a patient’s past and current needs, they will always contact myself, families or allocated social workers to gather as much information as possible to gain the best outcome for the patient and the current residents within the home.”

The home had a number of “discharge to assess” beds, these are specifically for people transitioning from hospital but who are not well enough yet to be back in their own homes without support. We saw evidence this process was safe and worked well.

Staff we spoke with understood the importance of ensuring family are informed and staff attended the hospital with people in the case of emergencies whenever possible. This ensured people had consistent support when moving between services. The provider recognised during the night this was not always possible due to staffing levels, however people would be sent with a “hospital pack” which would contain vital information about the person to support this transition.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff we spoke with understood how to recognise any potential signs of abuse and knew the process to escalate this appropriately to ensure people were safeguarded. The registered manager kept a safeguarding log to ensure they were meeting their obligations in relation to reporting safeguarding concerns, but also to identify any learning from incidents. Safeguarding concerns were discussed at monthly staff team meetings so all were aware and could learn from these.

The provider ensured they worked within the principles of the Mental Capacity Act (MCA) and people were kept safe and their rights upheld with Deprivation of Liberty Safeguards (DoLS). DoLS are a legal procedure to protect people who lack capacity and are deprived of their liberty.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People were actively encouraged to participate in positive risk taking to enable them to be as independent as possible, remain part of the community and enrich their lives. People were asked what they would like to do and the provider supported them to, as much as possible, do so. For example, they participated in regular outings into community, such as going to the pub or church.

A health care professional told us, “They cater to residents care and nursing needs and support them to be as independent as possible.”

Risks relating to people’s health and wellbeing were assessed, mitigated against and managed well. The registered manager kept a clinical risk register to have oversight of all the people living at the home which contained a clear overview of their needs and the potential risks relating to their health and wellbeing.

Clear guidance was in place to enable staff to safely support people with identified risks. We saw an example of someone being admitted with a severe pressure injury and within a few months were provided with effective care to fully recover from it.

Where any restrictive practice was used, such as bed rails or sensor mats, this was regularly audited to check for a best interest decision, risk assessment and that equipment was referenced in the care plan. This was in line with best practice and provided staff with clear guidance to support people in line with their individual needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Appropriate and regular checks were carried out on specific areas that could place people at risk, for example water temperatures and fire safety checks, to ensure people were kept safe.

Equipment used for assisting people with their mobility was regularly checked and health and safety audits were carried out.

People had personal emergency evacuation plans (PEEPs) in place that was easily accessible in a grab bag, which contained essential items, at the entrance of the home in the case of an emergency such as fire.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were supported to keep up to date with training relevant to their role to enable them to carry out their roles safely. Supervisions were conducted regularly, and a different topic was discussed at each such as hydration and falls to enable staff to safely support people.

The provider used a staffing dependency tool to calculate required staffing based on people’s needs to ensure safe staffing levels at all times on each unit. However, we did note that at night, whilst a safe staffing level was maintained, there may not be enough staff to support people in the case of an emergency, such as escorting them to hospital. Whilst most staff fed back positively about staffing levels, night staff did tell us on some units they felt short staffed, however rotas reflected the correct number of staff based on the dependency tool.

Families told us they felt there was enough staff to keep people safe, however one relative told us, “The carers do a fantastic job but there isn't enough 1-2-1.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

At the time of the assessment there was an outbreak of an infection, we saw safe practices and best guidance protocols had been implemented to mitigate the spread of infection in line with the providers Infection Prevention and Control (IPC) policy. Care and domestic staff were aware of the procedures that needed to be followed. Outcomes from IPC audits were discussed at team meetings to ensure all staff were aware and contributed to the cleanliness of the home, not just the housekeeping staff.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff stored, managed and administered medicines in a safe way. Controlled drug records were accurately kept and were stored safely in a locked cupboard. Where people had medication that posed further risks, such as anticoagulants, care plans were in place to guide staff.

We observed medicines being administered to people in a kind and patient way.