Jubilee Court Nursing Home

This responsive assessment focused on two key questions, safe and well-led. The purpose of the assessment was to check if the provider had met the requirements of the warning notice previously served in relation to good governance and their action plan in relation to safe care and treatment. This assessment was unannounced which means the provider was not told an assessment was going to be starting beforehand.At the last assessment, the provider was in breach of legal regulations in relation to safe care and treatment and good governance. Some improvements were found at this assessment. However, not enough improvements had been made, and we found a continued breach in relation to good governance.

Safety risks to people were not always managed well. Care plans and/or risk assessments were in place for people’s health care needs. However, we found staff did not always follow the plans. Improvements to medicines management had been made. However, we found processes had not always been followed by staff. Medicine audits completed by managers failed to identify the concerns which could have put people at risk of harm. The provider had not ensured all reportable safeguarding incidents were reported to CQC or/and the local authority safeguarding team. There were processes or systems in place when incidents had occurred to investigate them to find the root cause and prevent re-occurrence. However, the provider did not always ensure the findings from the investigations had always been put into place. Systems and processes had been implemented to provide an oversight of the service; however, these were not always effective as they had not identified the risks and concerns we found during our visit. There was clear governance, management, and accountability arrangements. Improvements had been made to obtains people’s and relatives feedback to drive improvements. Communication methods had been implemented such as a newsletter to keep people informed of changes. Changes to staff training had been made and some courses were followed up with observational checks to ensure staff were providing care in line with their training and to the providers standards. Staff felt supported and treated fairly by the management team.

We have asked the provider for an action plan in response to the concerns found at this assessment.