Random inspection report
Care homes for older people
Name: Address: Eversleigh 13 Sundridge Avenue Bromley Kent BR1 2PU two star good service 06/04/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Rosemary Blenkinsopp Date: 2 4 0 8 2 0 0 9 Information about the care home
Name of care home: Address: Eversleigh 13 Sundridge Avenue Bromley Kent BR1 2PU 02084642998 02084642998 eversleigh@cnvltd.wanadoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : C.N.V. Limited care home 31 Number of places (if applicable): Under 65 Over 65 31 old age, not falling within any other category Conditions of registration: 0 The maximum number of service users who may be accommodated is: 31 The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Eversleigh is a large, three-storey. Victorian-style house, converted for residential living, providing care and accommodation for older people. The home is set in wellmaintained gardens, with some off-road parking to the front. Residents accommodation is on the two lower floors accessed by a passenger lift and a stair lift. Central heating is provided to all areas of the home. There are grab rails and handrails on stairs, in passageways, toilets and showers. Bathrooms are fitted with specialist
Care Homes for Older People Page 2 of 8 0 6 0 4 2 0 0 9 Brief description of the care home bathing and toilet equipment, lifting aids are also available. All bathrooms, toilets, showers and bedrooms are fitted with a lock, which is accessible from the outside in case of an emergency. There is a telephone accessible and available to the residents, and several of the residents have one at their own expense. The home is maintained to a good standard. The newly developed top floor is very pleasant. Work is underway to the exterior parts of the building including the roof. Despite all the work that is in progress the residents are not being unduly inconvenienced. The fees range between £560- £1000 per week. Care Homes for Older People Page 3 of 8 What we found:
A visit was undertaken with Michael Williams, Regulation Inspector, to follow up actions taken by the home following a recent Adult Protection investigation. In particular the action plan, which the home provided following the adult protection investigation, was monitored to ensure points were being actioned. During our visit we looked at documentation; spoke to staff, met with the Acting Manager, Sue Johns and Jan Norman Group Manager. The action plan, which was produced by the home as a result of the Local Authority investigation had seven areas where the home stated action was to be taken. Our findings on the progress made on these are referred to below: It was clear from the documentation that we viewed that there was insufficient recorded evidence in the care plans, daily records and other records to show that the victim had been supported following the incident. In addition there was no specific indications as to what increased observation that the alleged perpetrator had received. Although a risk assessment had been produced the instructions for monitoring were not followed. The documentation needs to be improved upon to show clearly what support care and assistance resident receive. The second point was in relation to improving relationships with the family. The staff in the home are hoping to work with the family and this is ongoing. The third point was in respect of the families previous concerns they raised on other occasions when they visited the home. More efforts are now being made to engage with the family and any changes in the relatives health are reported immediately. This is ongoing. Delays did occur following the incident including delays in informing the victims family. Police were not called as Jan Norman and the GP took the decision that it was not needed and that there was police representation on the Adult Protection panel. The GP took the decision not to visit or examine the victim, hence no examination swabs or other medical intervention was conducted. Police were not contacted as indicated above until the family contacted them 22/6/09 when the family had been advised by Jan Norman of the event. The police took no further action on this matter. The home were slow to ensure that the residents in the service were afforded sufficient protection. Jan Norman stated it was for the residents safety and welfare that he was eventually moved to another home. The documents we viewed, which had been reviewed in light of this incident needed to be further amended to ensure staff had clear concise and prescriptive information on how to action Adult Abuse. In particular the policies and procedures need to be clear. In addition this would need to be supported by ongoing training and staff support with regular auditing measures in place. It was evident from one staff member whom we met, that she was unclear that the first
Care Homes for Older People Page 4 of 8 point of call for referral of adult protection matters namely the Local Authority Safeguarding Team. This needs to be actioned. The revised Adult Protection Safeguarding policies needed more clarity in respect that staff can report appropriate matters directly. Included in the information current telephone numbers for contacts, and the information updated as changes occur. Training needs to continue with all staff including ancillary workers so they are confident and competent in referring and dealing with actual or suspected abuse. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 8 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 9 18 Staff must have training and 20/09/2009 be regulaly updated in medication procedures. Staff who give out medicines need to be trained and competent in this area. 2 9 13 All information must be recorded in respect of medication particulaly allergies. To ensure residents have medication safely administered to them. 20/05/2009 3 25 23 The glass topped tables must 30/04/2009 be risk assessed and their suitability in this type of home reviewed. All areas of the home must be safe for residents to live in and free from potential harm . Care Homes for Older People Page 6 of 8 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action 1 18 13 All adult protection matters 30/09/2009 must be reported in a timely manner to the appropriate bodies. To ensure that investigations are conducted correctly. 2 18 13 All staff must be fully 30/09/2009 conversant with Adult Protection procedures and be aware of the telephone numbers for referral of such matters. To protect residents safety. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 7 of 8 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 8 of 8 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
