CQC report explained · a nursing home
What the CQC found at Jubilee Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely. Care plans did not always explain how to manage time-specific or high-risk medicines, although the home took action during the inspection.
- Effective?
- Good
- This key question was not inspected in this visit, so its previous rating carried over.
- Caring?
- Good
- This key question was not inspected in this visit, so its previous rating carried over. People and relatives spoke positively about the care provided.
- Responsive?
- Good
- This key question was not inspected in this visit, so its previous rating carried over.
- Well-led?
- Requires improvement
- Management systems had improved, including records about staff conduct, but medicines monitoring did not always identify where action was needed. The home was also without a registered manager at the time of the inspection.
What inspectors found, August 2023
Requires Improvement; inspectors found kind, improving care, but medicines were not always managed safely.
Inspectors visited without notice on 31 May and 1 June 2023. They spoke with people, relatives, staff and health professionals, observed care, and checked care records, medicines records and management systems.
People generally said they felt safe and spoke positively about staff. Inspectors found good safeguarding, infection control, personalised care and partnership working. Permanent care staff had increased, which improved consistency for people.
The main concern was medicines. Some care plans did not give enough information about time-specific or high-risk medicines, including an anticoagulant and seizure treatment. The home took some immediate action, but inspectors said its medicines monitoring systems needed further improvement.
The overall rating was Requires Improvement, the same as at the previous inspection. Safe and Well-led were both rated Requires Improvement. The other three ratings were not inspected and carried over from the previous inspection.
People felt safe
People were protected from abuse, and staff understood how to report safeguarding concerns. People and relatives said staff were attentive and would act if there was a problem.
“People were safeguarded from the risk of abuse.” from the report
More permanent care staff
The home had recruited and inducted more permanent care staff. Inspectors said this reduced reliance on agency staff and improved consistency for people.
“The provider had recently recruited and inducted a large number of permanent care staff.” from the report
Person-centred atmosphere
Inspectors found the home warm and welcoming. People said staff took time to learn about their history, preferences and what mattered to them.
“People told us that staff had taken time to get to know them and what was important to them.” from the report
Improved staff conduct records
The provider had acted on the previous recommendation about staff conduct. Records now showed how concerns were investigated and what action was taken.
“Records now contained a clear audit trail of how staff conduct had been investigated and what management decisions had been made to address concerns and mitigate risks to people.” from the report
Medicines care plans were incomplete
seriousSome care plans did not explain how staff should monitor or manage high-risk and time-specific medicines. This created a risk that people would not receive the correct care and treatment.
“Care plans were not always in place and did not always provide sufficient detail relating to time-specific medicines and high-risk medicines.” from the report
Nursing team consistency was still being developed
needs fixingThe home had improved consistency among care staff but was still trying to recruit more permanent nurses. Agency nurses had been block booked as an interim measure.
“They were now working to recruit more permanent nurses to reduce reliance on agency nurses and achieve the same consistency amongst the nursing team.” from the report
- 01How are you now checking that every person with a high-risk medicine has a detailed care plan?
- 02What guidance is in place for monitoring and responding to side effects from anticoagulants?
- 03What is the plan for recruiting permanent nurses and reducing reliance on agency nurses?
- 04Who is currently responsible for managing the home, and when will the manager apply to become registered?
- 05How will you show families that the new medicines working group tool has improved practice?
This was a focused inspection of Safe and Well-led; the Effective, Caring and Responsive ratings were carried over from the previous inspection. This explanation was written from the published report of 3 August 2023 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, April 2022
Jubilee Lodge rated Requires Improvement; inspectors found safe care in some areas but medicines, recruitment records and management checks needed strengthening.
Inspectors visited the home without notice on 9 and 10 March 2022. They spoke with people, relatives, staff and managers. They reviewed care records, medicines records, accident records, safety checks and management systems.
The overall rating was Requires Improvement. Safe was rated Requires Improvement because medicines records and some recruitment checks were not always complete or properly monitored. Staff understood safeguarding and there were enough staff to meet people's needs, but the home relied on agency staff because of vacancies.
Well-led was also rated Requires Improvement. A new management team was working through an improvement plan, but some actions were not yet fully in place. Records did not clearly show how two concerns about staff conduct had been investigated and managed.
The previous Safe rating was Good and has fallen to Requires Improvement. The Well-led rating remained Requires Improvement. The other three areas were not rated in this inspection.
Risk assessments
Inspectors found that risks such as falls, poor nutrition, pressure ulcers and mobility needs had been assessed and reviewed.
“Risks to people had been appropriately assessed and reviewed.” from the report
Positive views of care
People and relatives spoke positively about the care. People also said staff respected their privacy and dignity.
“People and relatives spoke positively of the care that was provided.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Incomplete medicines records
seriousSome records for medicines, creams, opening dates and fridge temperatures were incomplete. One allergy was missing from a medicines record, and audits had not found all the problems.
“Medicine related records were not always complete. This included records for some 'when required' medicines and topical creams and opening dates for some reduced shelf life medicines.” from the report
Concerns about staff conduct
seriousRecords did not show clearly how two concerns about staff conduct had been investigated or what decisions had been made to reduce risks to people.
“records did not provide an audit trail of how these concerns had been rigorously investigated, what management decisions had been made to address these concerns and mitigate risks to people.” from the report
Recruitment checks
needs fixingThe home was reviewing recruitment files, but inspectors needed more evidence that risk assessments were completed when all recruitment information was not available.
“More time was needed before we could judge that the provider's improvement actions would ensure that risk assessments where in place when all recruitment information could not be obtained.” from the report
Reliance on agency staff
needs fixingThere were enough staff at the inspection, but vacancies meant the home continued to rely on agency workers. Some staff said they might not always have time to respond flexibly to changing needs.
“There were enough staff to meet people's needs but due to staff vacancies, there continued to be a reliance on support from agency staff.” from the report
- 01What has changed in medicines recording and auditing since the inspection, including checks on allergies, creams, opening dates and fridge temperatures?
- 02How do you now record and investigate concerns about staff conduct, and how are risks to residents followed up?
- 03How many permanent staff vacancies remain, and how much agency staffing is currently being used on each wing?
- 04How do you make sure recruitment risk assessments and employment checks are completed before staff start work?
- 05What progress has been made on the service improvement plan, and how can families see evidence that changes have been sustained?
This was an unannounced focused inspection of Safe and Well-led; Effective, Caring and Responsive were not rated in this inspection. This explanation was written from the published report of 30 April 2022 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 Lodge
6 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2017Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- July 2016Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2015Goodup from Requires improvementResponsive: Requires improvement
- December 2014Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 2 August 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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38 live-in carers within about an hour of Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
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