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 improvement. At this assessment the rating has remained requires improvements.

This service scored 56 (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 listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The provider had processes and systems in place to investigate to find the root cause to incidents, to put measures in place to reduce or mitigate the incidents from reoccurring. However, we found the provider did not always follow the identified actions to take to reduce the incidents. For example, after an incident of a fall for a person, management had recommended a falls sensor to be fitted in a person’s bedroom to reduce falls. However, we found this action had not been completed. This meant people remained at risk.

Whilst learning had taken place after our last visit, and the provider had made changes to the service, we continued to find similar concerns with the environment, not always reporting safeguarding incidents and known risks to people not being managed in line with people’s care plans. This demonstrated the learning culture was not always effective.

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. People’s care plans were current and reflective to their care and support needs. Staff were provided with clear written guidance when changes had occurred to people’s care needs and where health professionals were involved. The provider continued to work closely with other professionals 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.

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. New systems and processes had been put into place for the management team to follow in relation to reporting safeguarding incidents to the local authority and CQC. However, we continued to find incidents where people had come to harm that should have been reported, had not always been reported. This meant people were at continued risk of harm. After our visit, we raised some incidents to the local authority safeguarding team that had not been reported. After our visit the provider told us they would reviewtheir processes and implement more detailed guidance for the management team to follow. Improvements had been made to investigating incidents of harm to find the root cause to ensure measures could be put into place to protect people. However, we found the measures were not always followed through. This meant people were at continued risk of harm.The provider had policies and procedures in place to ensure staff were open and transparent when care was not delivered as planned and harm was caused (duty of candour). However, we found the provider did not always ensure they met the duty of candour requirements, which include a verbal and written apology to people or their representative. The provider did work well with people and health care partners, where incidents had required emergency services or health advice this had always taken place. Staff and the management team had completed safeguarding training.

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. Care plans and risk assessments were detailed and provided staff with clear written guidance on people’s known risks and how to manage them safely. However, we found staff did not always follow the guidance. For example, a person had been assessed high risk of skin damage. Their mobility care plan stated they should use a pressure relief cushion when sitting on a chair. However, staff failed to follow the care plan. We observed throughout most of our visit the person was sat on a dining room chair for long periods of time and asleep with no cushion and no staff encouragement of pressure relief. People were also at increased risk from poor catheter care. For example, a person’s catheter care plan stated their catheter bag should be checked every 2 hours in the day and every 4 hours at night. Staff failed to follow the care plan as we found the monitoring records, showed the catheter was not always checked every 2 hours in the day or 4 hours during the night. This meant people were at risk of harm.

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.

The provider implemented new systems and processes to check the safety of the environment. However, we continued to find concerns. For example, we continued to find one of the fire doors was not clear of blockages and found food crates blocking a fire exit door. Immediate action was taken by the provider during our assessment. We also found people were at risk of harm due to a lack of security measures at the home. On our arrival we found all 3 main exit doors were wide open. Two of the doors we found led straight into the care home where people resided in. With the doors being left open, vulnerable people could leave the care home alone and a risk of members of the public entering the care home which places them at risk of harm. The provider told us they had taken action to ensure all the doors would be closed and secured. A people told us they, “had asked for a safe for the bedroom to put some sentimental jewellery. This had been promised, about four weeks ago, but had not materialised.”

They did not always work together well to provide safe care that met people’s individual needs. Improvements had been made to the training staff received. The provider implemented more face-to-face training and followed this with observational checks to ensure staff were competent. We reviewed rotas and they were in line with the providers staffing calculations. We observed there was enough staff on to provide people with care and support. However, we had observed there was not always sufficient staff to provide activities or meaningful engagement with people. We received mix feedback regarding sufficient staffing levels from people. We were told “In the daytime yes, [enough staff], nighttime, wait at night, about ten minutes”. “Sometimes they come quick, depends on where they are.”

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. We observed that hygienic practices were consistently maintained throughout the home.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Whilst improvements to systems and processes had been made to ensure time specific medicines were administrated at the correct times, we found staff did not always follow the providers processes. For example, the providers policy was for staff to record the time of administration for all time specific medicines, however we found several records where this was not completed. We found topical medicines were not always stored safely. We found topical medicines accessible and unsecured in some people’s bedrooms and in a communal bathroom. This could have placed service users living with dementia at risk of harm if they had access to these products and ingested them. There was a clear process in place for people who were prescribed medicines that should be taken before food had been administrated safely to ensure the medicines were effective. Staff told us they had completed medicine training and competency checks were completed to ensure they are administrating medicines safely.