Jubilee Court Nursing Home

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 requires improvements. At this assessment, the rating has remained requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment due to the way people’s medicines were managed, safeguarding incidents were not always reported, poor management of incident and accidents and safe fire practices were not always followed.

This service scored 47 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always investigate and report safety events to other stakeholders as required. Lessons were not always learnt to continually identify and embed good practice. We found accidents, incidents and falls were reported by staff, however they were not consistently investigated to find the root cause or reviewed by management. This meant learning could not take place to reduce the re occurrence of incidents.

We found audits of accidents, incidents including falls were not robust and failed to identify themes and trends to reduce or mitigate the re occurrence of them happening again. This placed people at continued risk of harm. Furthermore, records demonstrated staff had not been involved in reflecting after incidents to ensure learning could occur. We were not assured the duty of candour was always followed. For example, a person had a senor mat, a sensor mat alerts staff if someone has had a fall. The person had a fall, but the sensor mat had not alerted staff because the batteries needed replacing. This meant people were at risk of harm. There were no records to show people received an apology when things had gone wrong. There was no record if the person received an apology.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Care plans were not always current and reflective to people’s needs. For example, when changes had been made or agreed by health professionals this was not reflective in people’s care plans to ensure staff had up to date information. There was a risk if information needed to be shared with other stakeholder or emergency services the information would not be correct. The provider did work with other professional to ensure joined up working. For example, there was a multi-disciplinary visit from health professionals including a GP and nurse once a week to discuss any health concerns or risks. Relatives also told us they had other professionals involved in their care, one person said, “[person] has just had his catheter changed and the district nurse comes regularly to check it.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider did not always share concerns quickly and appropriately. We found there was not a strong understanding within the management team of safeguarding and what needed to be reported to the local authority or/and CQC. We found a number of incidents where people had come to harm that should have been reported but had not been. After our visit, we raised some incidents to the local authority safeguarding team that had not been reported and the provider told us they would review all incidents and report any that met the thresholds. We found processes were ineffective in investigating incidents of harm to find the root cause to ensure measures could be put into place to protect people. There was no evidence of how safeguarding incidents were analysed to identify lessons learned. This meant people were at continued risk of harm. Where incidents had happened, and an injury had been sustained staff had made contact with health professionals or emergency services to ensure people received the health care they needed. People told us they felt safe. One person told us, “Yes, I feel safe here they [staff] look after me well. I feel safer than if I was at home. They [staff] come in frequently to check on me.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. We found risks were not always assessed and care planned to ensure staff had clear written information and guidance regarding people’s known risks. We found concerns with people’s individual risk management, for example, monitoring charts and daily notes were not comprehensively completed. People’s care plans and risk assessments contained conflicting information and were not always accurate. One person had developed pressure damage to their skin and there was no risk management plan in place. Personal evacuation plans were not person-centred to ensure staff and emergency service would have accurate and up to date information on people’s support needs during an evacuation to ensure they could be evacuated safely. Relatives told us they were involved with risk management. One relative told us, “They discuss everything with me, they talked to me about what they [staff] wanted to do. We agreed [person] doesn’t get out of bed because [person] doesn’t like to wear [certain safety equipment to keep them safe].”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found a fault light showing on the fire alarm system. The provider told us this fault had been showing for 2 years of a sensor not working, and no oversight was in place to ensure adequate action was taken in a timely manner. We observed the home was not always safe in the event of needing to evacuate the care home. Two fire exits were not clear of blockages. We found concrete plants, a life size wooden ornament and food crates blocking the fire doors, meaning this would not allow people and staff to safely exit the building. We also found fire doors were wedged open. This meant people were at risk of harm from fire due to poor implementation of fire prevention practices. People and relatives told us they felt the environment was safe. One relative told us, “Because [person] has had a lot of falls, they [provider] have put another carpet down instead of a hard floor to prevent [person] from hurting himself. [Person] doesn’t press his buzzer. They have done everything they can to keep him safe.”

The provider did not always make sure there were enough qualified, skilled, and experienced staff. We were not assured staff had completed the required training to ensure they had the skills and knowledge to provide safe support. The training records did not demonstrate when staff had completed their training to evidence if staff training was completed or in date. This meant people were at risk from being supported by staff who did not have the right skills and qualifications. We received mix feedback from people regarding staffing levels. Some people told us there was always enough staff and others told us there were not. One person told us, “There are not always enough staff. Especially at weekends and because staff are constantly changing it can be difficult.” Another person said, “There are only two staff on at night [within their unit]. That is not enough if there is a problem with someone” The provider used to calculate staffing, we reviewed the rotas, which showed there were always 11 staff or more on the night shifts. During both onsite visits we observed there was enough staff to support people safely. People and relatives were positive about the staff team. They told us that they had no concerns about staff that supported people and the staffing levels at the home, staff were recruited safely. Records showed relevant pre-employment checks, such as criminal record checks, right to work in the UK, references and proof of the person’s identity had been carried out.

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. There were policies in place to guide good infection control practices. People told us they were happy with the cleanliness of the home and bedroom cleaning. One person told us, “Yes, it’s light and airy and really clean. That’s one of the reasons we chose this place”. We observed the environment was clean, and tidy. This included communal areas and people’s bedrooms. Regular checks were made to ensure effective infection prevention and control (IPC) practice was maintained. Domestic staff were visible. The laundry and kitchen areas were clean and well organised. The kitchen had a food hygiene inspection on 31 October 2024 and was rated 5 stars. This meant hygiene standards were very good and fully complied with the law.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. People were not involved in planning. The provider did not always make sure that medicines and treatments were safely administered. We found serious shortfalls in the management of medicines, placing people at risk from unsafe administration of medications. Staff told us that they had received training on how to manage medicines safely. However, we were not assured that staff understood the legal frameworks and national guidance around medicine management. We saw medicines were not always managed safely. For example, we found that where there was time specific medicine, this was not always administered at the specified times. Although there were times listed as to when the medicine should have been administered, records demonstrated the medicines were not always given at the required time. We found that there was no evidence that gaps had been given between certain medicines and consuming food. Without this gap, there could be an impact on the effectiveness of the medicine. When people were prescribed medicines on a when required basis (PRN), for some, there was no written guidance for staff to follow to ensure they were given consistently and appropriately. This placed people at risk of not receiving their medicines safely and at risk of harm. Whilst we found concerns with medicine management, people and relatives told us they had no concerns.