Inspection on 16/07/08 for Evergreen Lodge

This is the latest available inspection report for this service, carried out on 16th July 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Evergreen Lodge 21 South Park Hill Road South Croydon Surrey CR2 7DY Lead Inspector Michael Williams Key Unannounced Inspection 16th July 2008 09:50 Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Lodge Address 21 South Park Hill Road South Croydon Surrey CR2 7DY 020 8688 7711 020 8681 6908 manager.evergreen@careuk.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care UK Mrs Avril Ingrid Koroma Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 12 4th July 2006 Date of last inspection Brief Description of the Service: ‘Evergreen Lodge’ is owned and managed by Care-UK, a national organisation with services throughout the country. Their statement of purpose states, “Care UK Mental Health Partnerships is a wholly owned subsidiary of Care UK plc operating under the umbrella of Care UK Specialist Care Services”. This home is based in South Croydon; it is situated in a quiet suburban road but is near to transport and shops. Evergreen Lodge is Registered to provide care for up to 12 adults, 18 to 65 years of age, and who have mental health problems - many also have secondary issues related to offending behaviour and the misuse of ‘recreational’ drugs and alcohol. Evergreen Lodge has 12 single ensuite bedrooms and lounge and dining areas on each of its two floors. In addition to a fully equipped kitchen on the ground floor it also has a domestic scale kitchen suitable for rehabilitation support work with service users. Two of the bedrooms on the upper floor are set up as flats with their own kitchenettes and a lounge. The home has a reception area, an office, laundry, staff and meeting rooms. This project was set up by Care-UK in partnership with a local NHS Trust who therefore all places in this care home are reserved for placement through the local forensic mental health team. Fees in 2008 were set at £1900 per resident/week. Residents will pay for their personal requisites but any additional funding required for additional care will be negotiated with the funding authorities. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. To monitor all aspects of this service we ‘case-tracked’ the care provided to a sample number of residents and cross checked the information by speaking to the people who use the service, (in this setting ’people who use the service’ are residents and this is the term we use in this report). We also spoke to visitors and examined the documentation supporting care; we observed the meals provided; checked the arrangements for providing medication, handling money, records of complaints and accidents. Staff providing care were interviewed including team leaders, carers and ancillary staff (cook). Questionnaires were also distributed and seven feedback forms were returned to us. In compiling this report the Commission has also taken account of any other information such as the monthly reports provided on behalf of the owners of Care UK and the AQAA [Annual Quality Assurance Assessment] – which is a new self auditing tool each home is required to complete. The manager confirmed the placing arrangements and fees, she also confirmed that the details on the registration certificate, displayed in the entrance area, are correct. We are advised that there have been no substantive changes to the service since we inspected in 2006. What the service does well: What has improved since the last inspection? It is the residents’ opinion that this is, “A very good (care) home” and that they have, “No complaints” about the environment, the staff, the meals or the support and care they receive. All seven written feedback forms, from residents and staff, confirm that the correct level of support is being provided by Evergreen. This is a service that works closely with a local forensic mental health team (‘forensic’ referring to offending behaviour in this instance) and in particular with each resident’s ‘Care Coordinator’. The positive use of the provisions of the Mental Health Act, for example by receiving residents subject Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 6 to community orders, helps to provide therapeutic boundaries for residents enabling them to resettle into the community. Other aspects of this home were identified as good when we visited in 2006 and remain so including staff recruitment and training; care of the environment; record keeping and in particular care planning documentation are still of a high standard in this care home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): MNS 1 and 2: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to be given very detailed information about the service so that they can be assured that their needs will be thoroughly assessed prior to admission. EVIDENCE: We checked the statement of purpose, the service user guide and various other documentation including the assessments provided to the home at the time of admitting new residents. We also interviewed residents and staff about the admission process. All placement into this care home are made through a single mental health team and so there is a well established procedure for assessing residents and providing the home with very detailed assessments - including risk assessments and care planning objectives for the placement. It was clear from our observations that significant time and effort is spent planning to make admission to the home personal and well managed. Prospective residents, and where appropriate their families, are treated as individuals and with dignity and respect for the life-changing decisions they need to make. There is a high value on responding to individual needs for information, reassurance and support. Prospective residents need to make a commitment to accepting the support and boundaries offer by the home and this is set out in the initial documentation supporting the admission of each resident. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 9 Prospective residents are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and special attention to help them to feel comfortable in their surroundings and enable them to ask any questions about life in the home. All residents receive a contract to which they have agreed. It gives clear information about fees and extra charges, which is reviewed and kept up to date. This information is meaningful and can be provided in appropriate languages and formats but at present all residents can read and understand the standard written text and formats. The documents are also explained to individual residents, so they fully understand the information and this is seen by the staff team as a vital part of the admission process since residents are often subject to conditions imposed by Mental Health Review Tribunals or other Mental Health Act orders including compulsory drug testing conditions. The use of advocates to support people is being encouraged and two example of this were noted during our visit – in the case of residents with mental illnesses it is not unusual for the advocacy to be legal rather than social or informal. The statement of purpose restricts admissions to certain forms of mental illness whilst in practice residents with wider range of mental disorders have been admitted so the statement of purpose needs to be brought up to date to reflect changes in the Mental Health Act and the company’s policy on admissions. Areas of strength include the documentation supporting admission, the detailed analysis of residents’ needs and the well organise arrangements for admission; we recommend that the statement of purpose is updated to include the full range of mental disorders that the home is admitting. No matters requiring improvement arise and since this service has a track record of very good practice in this area we assess this section about admissions as excellent. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 6, 7, 8 and 9: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The ethos of this care home is that residents should feel they are in control of their lives and so staff are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible and in a manner that is safe for them and the wider community. EVIDENCE: The care plans we checked, four in all, are developed with, and acknowledged by the resident to whom they refer. Each is based upon a full and up to date holistic assessment so that it includes details of their mental health needs, their social and emotional needs as well as more practical aspect of their lives such as skills for daily living, shopping, cooking and managing money. The care plans include reference to equality and diversity and clearly addresses any needs identified in the six strands of diversity which are: gender, age, sexual orientation, race, religion or belief, and disability. The home has for example various aids and adaptations to assist less mobile residents and has a range of staff, male and female from a variety of ethnic origins so as to cater for the varying needs of residents. The home hold an annual ‘Diversity Day’ which Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 11 sounds great fun and gives everyone in the home a chance to celebrate their diverse backgrounds and to learn about other cultures. The assessments and care plans are focused on resident’s strengths and personal preferences and so it includes information such as who and what is important to them, how they keep safe, their goals and aspirations, their skills and abilities, and how they make choices in their life. Staff also ensure that the plans of care includes information about health and of course mental health issues including risks of relapse. It always celebrates the individual, their life experiences and sets out in detail how all their current requirements and aspirations are to be met through positive individualised support. The care plans we read include a great amount of details about the life history of residents so as to inform staff - as well as reminding the residents themselves - where risks lay as they re-integrate back into the community. Key workers actively provide one to one support, keep the care plan up to date and make sure that other staff always know the person’s current needs and wishes. Evergreen staff know and record the preferred communication style of the individual, and enable the person to fully participate in the care plan objectives and the running of the home. Care Plans are being reviewed regularly, and as the individual’s needs change. This process is usually led by the obligation imposed by the ‘Care Programme Approach’ which requires the community psychiatric service to maintain support and keep in touch with the resident. Reviews focus on asking questions about what has worked, where there is progress, achievements, concerns and what the plans are for the future. The care plan includes a comprehensive risk assessment, which is regularly reviewed. Any limitations on freedom, choice or facilities are always in the person’s best interests and are often fixed by legal authority such as conditions imposed by Mental Health Review Tribunals and other Mental Health Act orders. The residents we spoke to understood and agreed any limitations so imposed; they are fully documented and reviewed regularly as required. Where residents do not agree with conditions that have been imposed then they are supported by advocates to formally challenge the conditions. So it is clear from this evidence that residents know their rights and advocacy services are made available promote their rights. People using the service know, and are able to see, the records the home holds about them. Residents are continually consulted on how the service runs and are able to influence key decisions in the home but in reality few residents have much interest in the actual running of the home or in daily tasks such as cleaning and cooking but staff try to ensure they fully involved in decisions about the areas such as staff selection, the day-to-day life of the home, and its future development. Resident involvement in staff recruitment has proved very successful and is commended. Residents told us that they met with prospective staff and were assisted in asking relevant questions so as to assist the manager in recruiting new staff. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 12 Areas of strength include the exceptionally well organised and well documented care needs of residents; the residents involvement in the care planning and the reviewing and revising of care planning. Despite the historic risks associated with residents in this service the home supports residents progress towards increasing independence in a safe manner. No matters require improvement in this section about needs and choice and it is assessed as excellent. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12 to 17: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s key objective is the promotion of the residents’ right to live an ordinary and meaningful life in the community, so residents they can enjoy all the rights and responsibilities of citizenship. EVIDENCE: To evaluate this section of the report we spoke to staff and residents, and one ex-resident, and it was evident that Evergreen staff understand and actively promote the human rights of people using the service, with fairness, equality, dignity, respect and autonomy all being seen as central to the care and support being provided. The resident in this service have had the disadvantage of mental illness and often other disabling issues such as addiction to drugs and alcohol so the staff actively seek to bring respect and dignity back into the lives of residents. They try to do this by working with a legal and therapeutic framework that is more fully described in the next section about health care. Residents are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 14 arranging activities both in the home and the community. Routines are flexible and residents can make choices in major areas of their life. It is to be noted that residents often need the encouragement of staff to be more active and creative in their use of spare time and it is also acknowledged that for many residents leading a tranquil and “peaceful life” as one resident said is as important as any particular activity such as engaging in sports or learning a new skill. As the manager put it, residents often reach a ‘plateau’ of engagement with the service and this can still be seen as a positive outcome for a resident who previously may have had a chaotic and harmful lifestyle. Residents are often quite clear about what they will and will not participate in but despite some ‘resistance’ staff actively seek information to enable people to access education and work, including supported employment, and paid employment where they have the capacity. Sadly, as several residents pointed out, work opportunities are difficult to find work when they have been unemployed for several years. Nevertheless, outcomes for residents are positive, and there is evidence from what they told us that they are enjoying the life opportunities that they experience since discharge from a secure setting into this more open and relaxed – but supervised – atmosphere of Evergreen. We note and commend the home for allowing residents to care for their pets, including cat, in the home. The service actively supports people to be independent and involved in all areas of daily living in the home. This includes taking responsibility for shopping, planning meals, and meal preparation and includes individuals being supported to be independent in the process following training and support. Although residents are not always enthusiastic ‘housekeepers’ the home has excellent facilities for in-house training for life skills; this includes no less than four kitchens in a home for just 12 residents. There is main kitchen (with an employed cook), a large residents’ kitchen also used by visiting Occupational Therapists to assess and support kitchen skills and finally a pair of kitchenettes in the two residents’ flats used for the final stages of preparation for independent living. A highly commendable arrangement for catering in this type of service. Meals are very well balanced and nutritional and cater for varying cultural and dietary needs of residents. Mealtimes are flexible and relaxed, staff are patient and helpful particularly is supporting residents towards a ‘healthy’ eating diet and away from fast food and take-ways – we acknowledge that pre-cooked and frozen meals are used by residents and form part of meal-time routine that will equip them for life in independent accommodation. Areas of strength include the involvement of residents in the running of the home and their individual day-time activities supported by a well planned environment. No matters requiring improvement arise. This section about lifestyle is as assessed as good. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 18, 19 and 20: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive effective personal and healthcare support using individualised care plans based upon the rights of dignity, equality, fairness, autonomy and respect of residents so they can be assured their complex needs can be met. EVIDENCE: The statement of purpose, although it needs amending as outlined in the first section of this report, sets out the competencies and specialist services the home offers and delivers this effectively through a skilled, trained and knowledgeable staff group that work in a ‘person centred’, that is an individualised way with residents. Staff are highly aware that the way in which support is given is a key issue for younger adults. Individual plans clearly record people’s personal and healthcare needs and detail how they will be delivered. The care planning documentation is voluminous and contains both in-house planning information and assessments and objectives provided by the supporting mental health team. Practices in the home reflect residents’ needs under the six strands of diversity: gender, age, sexual orientation, race, beliefs and disability. For example the home has adaptations for disability, it has mix of staff to accommodate resident’s choice, it gives training in all aspects of diversity. So Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 16 the staff group is balanced to enable choice of male, female and age related preferences when delivering personal care. Staff ensure that care is person led, personal support is flexible, consistent, and is able to meet the changing needs of the residents. Staff respect people’s preferences and have expert knowledge about individual personal needs when providing support, including issues relating to their severe mental health problems. Aids and equipment are provided to encourage maximum independence for people using services. Specialist advice, for example by an Occupational Therapists, is sought by the home to ensure effective use of equipment such as the kitchen used by residents for learning skills for daily living. Residents, particularly younger adults, are encouraged to manage their own healthcare – particular to be aware of their medication, to take it as prescribed and to keep in touch with their psychiatric team and care coordinator. They have the opportunity to choose their own GP and have access to all NHS healthcare facilities in the local community. Regular appointments are seen as important and there are systems to ensure they are not missed. The home arranges for health professionals to visit residents at home when necessary. The home fully respects the rights of people in the area of health care and medication. They recognise and work with the decisions made by the individual regarding any refusal to take medication, or any specific requests about how their healthcare is managed. Since medication plays such a vital role in the well-being of residents in the care home this aspect of their care is closely monitored and any lapses are reported immediately to the mental health team. It is often a condition of residence that residents comply with treatment regimes. In order to support compliance some residents are subject to orders under the Mental health Act such as Section 25A (which deals with supervision in the community) and Sections 37/41 (which also deals with residents released from secure settings with conditions for compliance imposed upon them); Guardianship (Sections 7 or 37), which is similar in effect to Section 25A, has also been considered as a potentially useful way to support and set boundaries for some residents though none are subject to this order at present. The home sees these arrangements as setting much needed boundaries for residents within which they can begin to lead ordinary and fulfilling lives. We commend the home and its supporting mental health team for this innovative use of legislation so as to enhance the freedoms of residents in the longer term. Since residents will have been in hospital before admission to Evergreen they are entitled to ‘Aftercare (Section 117 of the Mental health Act) and staff ensure the Care Programme Approach meetings take place regularly and that psychiatric support is sustained by the relevant mental health teams. From speaking to staff and reading the case notes it is evident that staff members need to be and are very alert to changes in mood, behaviour and general wellbeing of residents and they fully understand how they should respond and take action – contingency plans are set out in the risk assessments Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 17 Staff are well trained and competent in mental health care matters. The home arranges training on health care topics that relate to the health care needs of the residents such as mental illness drug addiction and offending behaviour. The home has developed efficient medication policy, procedure and practice guidance. Staff all have access to this written information and understand their role and responsibilities. The home strongly promotes independence and those individuals assessed as being able are encouraged and supported to manage their own medication. Medication records are seen as key to the efficient management of health care matters, the home consistently keeps them up to date. The home has a sustained record of full compliance with the administration, safekeeping and disposal of all drugs. Care staff have the suitable training in the safe administration of medication. They are supported in this by the mental health team, which in many instances supplies medication for individual residents. Areas of strength include the well planned mental health care provided including the specialist use of Mental Health Act conditions. No matters requiring improvement arise in this section about care. It is assessed as excellent. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 22 and 23: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment so residents feel listened to and protected. EVIDENCE: The service has a complaints procedure that is clearly written and easy to understand and could be made available on request in a number of formats such as large print but at present this is not needed by any of the residents. Both in our meetings with residents and in the written feedback we received we learned that residents and others involved with the service know how to complain or make suggestions for improvement. The complaints procedure is supplied to all residents, in their copy of the ‘service user guide’ and is displayed in a number of areas within the service. Residents told us that they know how and to whom they can make a complaint and are clear about what will happen if a complaint is made. The home keeps a record of complaints and this includes details of the investigation and any actions taken, we checked the records to confirm this. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. We interviewed several staff and asked them about their training in respect of the protection of vulnerable adults from abuse and it was clear they knew about the home’s policies, the local authority procedures and the general ethos of the home – to protect resident from abusive behaviour. They have copies of the General Social Care Council’s ‘Code of Practice’ which sets standards of conduct for staff in caring situations. We note and commend the staff’s clarity Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 19 of understanding that any suspicion of abuse is to be reported and acted upon without delay – using, where appropriate the company’s ‘blow the whistle’ policy to report to external agencies such as Social services or the Commission. Training is available around related issues such as restraint and dealing with physical and verbal aggression is also made available to staff as needed. We are advised that staff do not restrain residents and so no record of restraint is maintained. Areas of strength include the clear complaints procedures, the openness of the home to suggestions and complaints and the staff awareness of abuse issues. No matters requiring improvement and so this section, about complaints and protection, is assessed as good. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 24 and 30: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical environment of the home provides for the individual requirements of the residents who live there, it is homely, clean, safe, comfortable and well maintained so we judge it to be appropriate for the particular lifestyle and needs of the residents. EVIDENCE: Evergreen was registered in 2006 when the premises were considerably refurbished so the home is very well appointed with large single rooms that have ensuite showers and toilets. The home was assessed as fit for purpose at the time of registration and this has proved to be the case. There are communal areas, dining and sitting rooms on each of the two floors and the home is in good decorative order. There is main kitchen, a secondary kitchen for residents to use and small kitchens in the two ‘flats’ on the top floor of the home; these are used for rehabilitation and preparation for more independent living. Adjacent to this kitchen is room now used as staff room but it has a Yale-type lock that could be deadlocked and should be replaced by a safer version. We noted that bedroom door was being wedged open; such wedges should be replaced by magnetic door holder as discussed and agreed with manager. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 21 The home was clean and tidy when visited and was free of offensive odours. There are adequate bathing and laundry facilities in the home. The home employs a cook and a cleaner to ensure good catering and hygiene standards are maintained and this staff arrangement is commended. Overall standards in this area about the premises are assessed excellent. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 32, 34 and 35: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home – so this will ensure that their needs are being met. EVIDENCE: On duty on the day of inspection was the manager, her deputy, three carers a cook and a cleaner; there were ten residents (two vacancies). We are assured by the manager that this staffing ratio meets the current needs of residents. The service has a well developed and executed recruitment procedure that has the needs of residents at its core. The recruitment of good quality carers is seen by the manager as integral to the delivery of an excellent service. The service is highly selective, with the recruitment of the right person for the job being more important to the filling of a vacancy. Residents are involved in the recruitment of staff and receive training and support to do this; the manager and one of the residents explained to us how this had happened in the last round of recruitment and proved very successful. The service has staff available at all times to support the needs, activities and aspirations of residents in an individualised way. The service is innovative and shows a high level of awareness of staffing levels needed; for example the Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 23 home has a hierarchical staff team with manager, deputy, team leaders and care workers - this provides leadership and skills at all levels. The service is proactive rather than reactive in its staffing, recruitment and training, with planning for the potential needs of people who may use the service in the future. The result of this is a diverse staff team that has a balance of all the skills, knowledge and experience to meet people’s needs. Management prioritise training and facilitate staff members to undertake external qualifications beyond basic requirements this is confirmed the home AQAA (the annual self assessment) which shows that all staff have received suitable training and qualifications. The home has internal developmental training, to complement formal training as part of an ongoing training plan so, for example, two staff were meeting with an assessor to enrol in NVQ (National Vocational Qualification) course work later this year. The staff team support each other and share skills and knowledge with colleagues. The roles and responsibilities of staff are clearly defined and understood, based on accurate job descriptions and specifications. Residents and others associated with the service report that staff are very skilled in their role; resident told us that the staff are “very good”, “helpful and very supportive” and that they thought staff helped them to be more independent. Evergreen has various quality assurance systems in place to ensure views are gathered and acted upon. The employer, Care UK, demonstrates that they are proactive and have a very good understanding of equality and diversity throughout the recruitment, induction and training process. These processes reflect the service’s understanding of the six strands of diversity: gender, age, sexual orientation, race, religion or belief and disability. Unusually for a care home in this part of London the mix of residents and staff is very well matched both in respect of gender and ethnic background, not all home are able to provide residents with choice in this respect. The home has an open and inclusive attitude to issues of sexual orientation and to people’s belief systems. The service sees induction and probationary period as vital to the success of staff recruitment and retention. The content of the induction and probationary periods are seen by manager and the staff themselves to be very thorough. Induction training exceeds Skills for Care requirements and could include person centred planning and thinking. The service only confirms permanent employment when satisfied that competence and progress has been shown to be satisfactory against their high standards. There are contingency plans for cover for vacancies and sickness; this has been demonstrated during June and July when a number of staff has been absent at short notice through sickness and other personal issues; the manager assures us that there is an absence issues in the home a series of absences is coincidental and that the staff team are loyal reliable. Key workers may have specific allocated time to spend with each resident and they have the skills to communicate effectively with the residents - who are themselves often very articulate knowledgeable people. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 24 Staff meetings are used for consultation and training and staff, including night staff, are involved in the development of the service. All staff have the opportunity to attend meetings and to be kept fully informed and able to contribute to meetings. Individual supervision sessions take place regularly and staff say that they find them useful for their development and can demonstrate practical outcomes. We noted that three supervision sessions were booked for staff on the day we made our visit and staff agreed to defer these meetings so as to assist in the inspection – assistance and cooperation is acknowledged. In our discussion with staff as well as the residents it was clear that staff understand and are aware of the specific nature and uniqueness of the home, its aims and objectives and how care will be delivered. Areas of strength are well safe and organised recruitment of staff, their deployment in the home and the skills and knowledge they bring to bear in this service. No matters requiring improvement arise. This section, about staffing is assessed as excellent. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 37, 39, 41 and 43: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives so residents can be assured that this is a well run service. EVIDENCE: The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’ operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Equality and diversity, human rights and person centred thinking are given priority by the manager who is able to demonstrate a high level of understanding and demonstrate best practice in these areas. The way the home is run shows an understanding of people’s needs in respect of the six strands of diversity: gender, age, sexual orientation, race, religion or belief, and disability. The manager demonstrates through formal qualification, robust operational systems and or professional experience and ability that she is knowledgeable Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 26 and highly competent in a range of areas such as good practice in he field of mental aftercare, understanding current legislation including the Mental Health and Mental Capacity Acts and the importance and purpose of having effective quality assurance systems. Staff see the manager as an imaginative and effective leader who consistently provides high quality services. They undertake regular training and understand and value opportunities for their continuing professional development. The manager ensures that staff follow the policies and procedures of the home and Care Uk as an organisation as well. Staff told us that they have access to training materials and documents. Practice and performance are discussed during supervision, staff training and team meetings. Spot checks and quality monitoring systems provide management evidence that practice reflects the home’s and organisation’s policies and procedures. There is strong evidence that the ethos of the home is open and transparent. The views of both residents and staff are listened to, and valued as they confirmed during our visit. The AQAA, which is a self-assessment document, contains excellent information that is fully supported by appropriate evidence for example record keeping, policies and practice that we observed during our visit. Insurance cover ensures that the home or corporate body are fully insured to meet any loss or legal liabilities. The home has efficient systems to ensure effective safeguarding and management of residents’ money and valuables, including record keeping – although at present all residents receive their money directly and not through Evergreen, but systems are in place if the need arises. So at present all residents are being supported to manage their own money. Record keeping is of a consistently high standard. Records are kept securely and staff are aware of the requirements of the Data Protection Act. Residents can gain access to their records and contribute to them. All the working practices in the home appear safe and there are no obvious preventable accidents that were made aware of when we checked the accident/incident records. The home has a comprehensive range of policies and procedures to promote and protect residents’ and employees’ health and safety. Staff are trained, understand, and consistently follow these. We did identify one potential hazard in respect of large mirror that was leaning against a wall near a shower cubicle and so we drew this to the attention of staff so that it can be risk-assessed and made safer. There is full and clearly written recording of all safety checks in their maintenance record folder and there is no evidence of a failure to comply with statutory reporting requirements and other relevant legislation. The home proactively monitors its health and safety performance and consults other experts and specialist agencies about health and safety issues as required. There is evidence of organisational monitoring by corporate providers. The manager, senior team, and staff at all levels have a good understanding of risk assessment processes which is underpinned by promoting independence, choice and autonomy. These principles are taken into account in all aspects of Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 27 the running of the home – in this home this includes detailed risk assessment of mental health related issues and most importantly these assessments also include contingency plans. The quality assurance system confirms that the findings from risk assessments have been followed-up and the home continuously improves its health and safety systems. As required the home is visited on behalf of the Directors of Care Uk but we were told that these visits (required by Regulation 26) are undertaken by other home managers and not a more senior manager in the company; we are therefore recommending that the monthly visits on behalf of the owners be conducted by a person that is senior to the home’s manager so as to represent, and report to, the owners/directors of the company. Three items require attention; they are to replace wedges with more suitable door-holding device such as magnetic door holder, and secondly to risk assess the use of large glass mirror in a shower-room. Thirdly a Yale-type lock is in use for the lounge/staff room and should be replaced with lock that cannot be deadlocked. In the first section of this report we also advised that the statement of purpose be reviewed. The manager advised us that these matters are already under consideration, not least because the service is now over two years in existence and the company, Care UK and the purchasing contractors, a local PCT (Primary Care Trust) wish to review progress and future developments. Areas of strength include the overall management of this service by a very competent manager, all aspects of the service appear to be very well managed including administration, matters of safety, resident care staff recruitment and support. Matters requiring improvement include the risk assessment of a large mirror and the replacement of door wedge. We recommend a senior manager conduct the monthly Regulation 26 visits and that this person ensures their reports are submitted to the Directors of the company. This section, about the management of the home, is assessed as excellent. Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME: Excellent Standard No Score 1 3 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES: Excellent Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Good Standard No Score 22 3 23 3 ENVIRONMENT: Excellent Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING: Excellent Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME: Excellent Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X LIFESTYLES: Excellent Standard No Score 11 4 12 3 13 4 14 3 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT: Excellent Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X 3 X 4 Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations Statement of Purpose: It is recommended that this document be updated to reflect changes in the Mental health Act and changes to the admission criteria; this is so prospective resident will know if the home will be able to meet their needs. Environment: magnetic door holders are recommended where resident wish to keep their bedroom door open; this is so they may do so safely. Environment: it is recommended that the home revaluate the use of large mirrors; this is so as to ensure the safety of residents. Environment: It is recommended that he Yale-type lock be replaced with safer version; this is so residents cannot deadlock this lounge/staff room. Management: It is recommended that the service review the arrangements for Directors’ monthly visits so as to ensure a person of suitable sanding in the company is conducting these visits. 2 3 4 5 YA24 YA24 YA24 YA43 Evergreen Lodge DS0000066263.V366947.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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