Jubilee Lodge

Updated 3 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two Inspectors, a member of the CQC medicines team and an Expert by Experience carried out the inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Jubilee Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Jubilee Lodge is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection the registered manager had recently left the service and so there was not a registered manager in post. Another manager had been appointed and planned to submit an application to register. This manager supported the inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 12 members of staff including the manager, area operations manager, quality improvement lead, agency nurse, head of dementia care, activities co-ordinator, chef, 3 care staff and 2 care leaders. We spoke with 11 people, 1 professional and 9 relatives to gather their experiences of the care provided.

We reviewed 3 people's care records, a sample of records relating to management of the service including health and safety checks, accident and incident records and policies and procedures.

We checked policies and records for managing medicines and reviewed 10 people's medicines administration records.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We sought feedback from a further 3 professionals to gather their experiences of the care provided.

Updated 3 August 2023

About the service

Jubilee Lodge is a residential nursing home providing accommodation, personal and nursing care to up to 74 people across four separate wings. The service provides support to people with nursing needs and people who live with dementia. At the time of our inspection there were 55 people using the service.

People’s experience of using this service and what we found

We saw improvements had been made since our last inspection as quality assurance systems to monitor the safety of the home through audits and staff management had been strengthened. Records had now been maintained to show how staff related concerns had been safely and effectively managed. However, we identified some concerns in relation to medicines specific care plans. We have therefore made a recommendation about the governance and oversight of the management of medicines.

People were protected from the risk of abuse, and the provider had systems and processes in place to safeguard people. People and relatives told us they felt safe and were positive about the staff who supported them.

The service worked in partnership with health and social care professionals to ensure people had the best outcomes.

The provider was working towards greater consistency for people and had increased permanent care staff to reduce the reliance upon agency staff. The provider was now looking to achieve the same consistency amongst the nursing team. The improvements already made in staffing had positively impacted upon personalised care for people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and relatives spoke positively of the care that was provided. One person said, “I have no criticism at all. I have no dependents and I am very grateful to be here…It is the answer to my prayers. This is my home.”

Quality assurance processes included a variety of audits. Despite the concerns we raised in relation to medicines, it was evident that the manager had a clear oversight of the service and how to sustain and develop ongoing improvement.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 28 April 2022).

At our last inspection we recommended that the provider review their systems to respond, investigate and monitor concerns relating to staff conduct. At this inspection we found the provider had acted on the recommendation and made improvements in this area.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Jubilee Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified a breach in relation to safe care and treatment relating to medicines management at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.