CQC report explained · a residential care home
What the CQC found at Jubilee Villa Care Home Ltd
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found improvements to risk assessments, fire safety, hazardous substances and infection control. They were somewhat assured that the building layout supported shielding and social distancing.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- The provider had introduced focused checks and revised risk assessment systems. Inspectors found enough improvement to end the breach relating to governance, but the whole key question was not assessed.
What inspectors found, May 2021
Inspected but not rated; inspectors found important safety and management improvements, but the home still had a previous Requires Improvement rating.
This was an unannounced targeted inspection on 10 May 2021. One inspector checked whether the home had met the requirements of two previous warning notices. The inspection focused on specific concerns, not the whole service.
Inspectors found that the home had improved its risk assessments, fire safety, infection control measures and quality checks. They found that the home was no longer in breach of Regulations 12 and 17.
The overall rating did not change and remained Requires Improvement from the previous inspection published on 29 April 2021. Safe and Well-led were inspected but not rated because only selected parts were checked. The other key questions were not assessed during this visit.
Reduced environmental risks
The home fitted or replaced window restrictors, replaced fire doors and cleared escape routes. It also secured hazardous substances and covered hot water pipes.
“The provider had reviewed their fire safety and prevention measures and taken action to minimise the potential for harm as a result of a fire.” from the report
Improved infection control
The home improved handrails, door handles, wash basin access and other parts of the building. It also completed immediate actions from a Legionnaires' risk assessment.
“The provider had acted to address previous concerns with the physical environment which hindered effective infection prevention and control practice.” from the report
Better quality checks
The provider introduced focused checks on the environment and revised the way risks were assessed. They also sought advice from care and safety professionals.
“The provider had reviewed their systems to monitor the quality of the service they provided.” from the report
Previous breaches addressed
Inspectors found enough improvement for the home to no longer be in breach of the two regulations covered by this targeted inspection.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Building layout and social distancing
needs fixingInspectors were only somewhat assured that shielding and social distancing rules were being met because the building layout did not support them effectively.
“However, the physical layout of the building did not effectively promote this.” from the report
- 01What has been done to make social distancing and shielding work safely in the building layout?
- 02How are the new environmental and risk assessment checks completed and reviewed?
- 03How are fire doors, escape routes, window restrictors and hot water pipe covers checked now?
- 04What immediate actions from the Legionnaires' risk assessment have been completed, and how are they monitored?
- 05When will the home receive its next comprehensive inspection covering all five key questions?
This was a targeted inspection of specific parts of Safe and Well-led, including infection control; it did not assess the whole service, and the previous Requires Improvement rating remained unchanged. This explanation was written from the published report of 14 May 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, April 2021
Rated Requires Improvement; inspectors found risks with safety checks, infection control and oversight, although care was effective in several areas.
Inspectors visited on 12 April 2021 after concerns about the environment and infection prevention. They spoke with people and staff, observed care, and checked care plans, medicines records and the provider’s checks.
They found people were not always protected from avoidable harm. Problems included unsafe window restrictors, fire safety issues, unsecured cleaning products, uncovered hot water pipes and poor infection control. The provider also lacked an effective Legionnaires’ disease risk assessment.
The home was rated Good for Effective. People received their medicines, food and healthcare support, and staff understood their duties under the Mental Capacity Act. However, Safe and Well-led were rated Requires Improvement because safety and quality monitoring systems were not effective.
The last rating was Good, published on 5 February 2020. After this inspection, the provider said it had completed actions including a Legionella risk assessment and fire safety work. CQC required an action plan and said it would monitor progress and inspect again.
Medicines and staffing
People received their medicines as prescribed and there were enough staff available to support people when needed.
“People were supported by enough staff who were available to safely support them.” from the report
Effective support
People’s needs were assessed and staff had the skills, training and support to provide care. People were also helped to access relevant healthcare services.
“People continued to be supported by staff who had the skills and knowledge to support them effectively.” from the report
Choice and involvement
People were involved in decisions about their lives, including what to do and what to eat. Staff supported people in the least restrictive way and in their best interests.
“People told us they felt involved in decisions about where they lived including what to do and what to eat.” from the report
Environmental safety
seriousInspectors found several risks, including missing window restrictors, fire safety problems, blocked escape routes, unsecured cleaning products and uncovered hot water pipes.
“The provider failed to ensure adequate fire safety and prevention measures were in place.” from the report
Infection control
seriousWorn surfaces, dirt, rust, a used glove and blocked access to a handwashing sink made effective cleaning and handwashing more difficult. There was also no Legionnaires’ disease risk assessment.
“The provider failed to follow safe procedures for preventing the spread of infectious and communicable illnesses.” from the report
Weak quality checks
seriousThe provider’s audits did not identify important safety and infection control problems. Staff were not always challenged when unsafe practices were found.
“The provider had ineffective systems to monitor the quality of the service they provided.” from the report
Poor decoration
minorThe home’s cosmetic appearance was poor and needed refurbishment. The provider said investment had been delayed while seeking to buy the premises.
“The cosmetic appearance of the home was poor and in need of refurbishment.” from the report
- 01What evidence can you show that the window restrictors, fire doors, escape routes and hot water pipes have been made safe?
- 02What changes have been made to infection control, including cleaning worn surfaces, the rusted hoist and communal equipment?
- 03Has the Legionella risk assessment been completed, and what actions did it identify?
- 04How are audits now checking for environmental, fire safety and infection control problems?
- 05How are staff challenged and retrained when unsafe practices, such as leaving hazardous cleaning products unsecured, are found?
This inspection examined Safe, Effective and Well-led; Caring and Responsive were not rated in this report. This explanation was written from the published report of 29 April 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.
Every inspection of Jubilee Villa Care Home Ltd
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- May 2021Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- April 2021Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- August 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017
Registered with the Care Quality Commission on 6 February 2017.
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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