CQC report explained · a nursing home
What the CQC found at Jubilee Court Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2021
Rated Requires Improvement; inspectors found good pressure-care, infection-control and staffing arrangements, but weaknesses in incident reviews, medicines processes and management oversight.
The inspection was unannounced and took place on 15 and 23 February 2021. Inspectors spoke with three people, 16 staff and health and social care professionals. They reviewed care records, medicine records, recruitment files and management records.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found that people were generally kept safe, with good pressure-care processes, infection control, staffing and safeguarding arrangements. However, medicines records and the review of accidents and incidents were not always reliable.
The inspection followed a specific incident in which a person died. It was also requested by the Nottinghamshire Coroner to check whether there was any continuing risk to other people. The overall rating fell from Good at the previous inspection, published on 3 July 2019.
The home breached Regulation 17 on good governance because managers had not consistently reviewed and signed off incident records. The provider was asked for an action plan, and CQC said it would monitor progress and return to inspect again.
Pressure-care arrangements
The home had introduced a clearer process for identifying pressure sores and responding to wounds. Records reviewed showed this process was working well.
“All records viewed showed this process was effective and pressure care management was completed well, reducing the risk of people experiencing avoidable harm.” from the report
Infection control
Inspectors found strong arrangements to reduce the spread of infection, including COVID-19. Staff were seen cleaning higher-risk areas regularly.
“Measures to prevent the spread of infection including COVID-19 were robust and effective.” from the report
Staffing and recruitment
There were enough suitably experienced staff to keep people safe, and recruitment checks reduced the risk of unsuitable staff being employed.
“Robust recruitment procedures were in place to reduce the risk of people being cared for by inappropriate staff.” from the report
Working with other services
The home worked regularly with health and social care professionals to review people's care and respond to their needs.
“Effective working relationships were in place with other health and social care agencies.” from the report
Incident reviews
seriousManagers did not consistently check and sign off accident and incident records. This meant staff actions were not always reviewed by management and led to a breach of Regulation 17.
“37 forms were looked at during the inspection and all 37 had not had manager sign-off.” from the report
Medicines records and storage
seriousRecords for medicines given when needed were inconsistent. Inspectors also found concerns about covert medicines, patch records, opened medicines and medicines stored in unlocked cabinets.
“The system for recording the support people received with their medicines was not consistent and increased the risk to people's health.” from the report
Training gaps
needs fixingSome staff training was not up to date, including training on deprivation of liberty safeguards, moisture-related skin damage and record keeping.
“We did note there were some gaps in some areas of training such as; 'deprivation of liberty safeguards', 'react to moisture' and 'record keeping'.” from the report
Duty of candour understanding
needs fixingManagers had limited understanding of the legal requirement to be open and honest when something goes wrong. Inspectors reminded them about investigating mistakes and apologising to people affected.
“The registered manager and home manager had a limited understanding of duty of candour legislation.” from the report
- 01How are all accidents and incidents now reviewed and signed off by a manager?
- 02What changes have been made to medicines records, storage and covert medicine arrangements?
- 03Have all staff completed the training gaps identified in the report?
- 04How do managers now make sure duty of candour requirements are followed when something goes wrong?
- 05What progress has been made with the action plan requested by CQC?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 25 March 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2019
Jubilee Court Nursing Home was rated Good; inspectors found kind, person-centred care, with some records and oversight needing improvement.
This was an unannounced inspection on 4 and 5 June 2019. Inspectors spoke with people living in the home, relatives, staff and a visiting health professional. They also observed care and checked care, medicines, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that risks and medicines were generally managed safely, staff were trained, and people received kind, respectful and personalised care.
There were some smaller shortfalls. Information about some 'as and when required' medicines was missing, lunchtime oversight could be better, some legal representative details were absent from care files, and audit arrangements were not always robust. The provider said these issues had been addressed or improvements were planned.
Risk and medicines management
Risks were regularly reviewed and staff had guidance to reduce them. Staff administering medicines were trained and their competence was checked.
“Risks to people were regularly assessed and reviewed. Guidance was available for staff in how to minimise risk to people.” from the report
Kind and respectful care
Inspectors saw warm and respectful interactions. Staff knew people well and supported their privacy, dignity, choices and independence.
“People were cared for in a kind and respectful manner. Good relationships between people and staff had been formed.” from the report
Personalised support
Care was based on people's individual needs and preferences. Staff received up-to-date information about changes at handover.
“People received care that was person-centred and based on their individual needs.” from the report
Staff skills and health support
New staff received an induction and shadowed experienced staff. The home worked with health professionals and made timely referrals.
“Records showed that referrals were made to other professionals as needed in a timely manner.” from the report
Missing medicines information
needs fixingGuidance for some medicines taken when needed was incomplete. The provider sent information after the inspection saying this had been put right.
“However, we did find some information in this area was missing.” from the report
Lunchtime oversight
needs fixingMost people enjoyed the food, but inspectors found that some people's lunchtime experience needed more staff oversight. The provider planned regular lunchtime observations.
“Whilst lunch was a pleasant experience for most people we identified other people's lunchtime experience could be improved through more staff oversight.” from the report
Quality audit scheduling
needs fixingAudits were used to monitor quality, but some might not happen when the person responsible was away. The provider sent details of a more robust schedule after the inspection.
“However, we identified that the schedule of audits could on occasion not take place if the designated person to undertake them was on leave.” from the report
Legal representative details
minorSome personal care files did not include information about legal representatives, such as people with lasting power of attorney. The provider said this would be added.
“People's personal care files did not always contain information about their legal representatives such as those with lasting power of attorney.” from the report
- 01What information is now recorded for medicines that people take 'as and when required'?
- 02How are lunchtime observations carried out, and what changes have they led to?
- 03How do you make sure quality audits still happen when the designated person is on leave?
- 04Do all care files now record legal representatives and lasting power of attorney details where relevant?
- 05How are staffing levels checked against people's changing needs, given the mixed feedback about staffing?
This was an unannounced inspection covering all five CQC questions, and all five ratings remained Good from the previous inspection. This explanation was written from the published report of 3 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Jubilee Court Nursing Home
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- March 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Goodstayed GoodSafe: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Registered with the Care Quality Commission on 10 December 2012.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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