Inspection on 15/02/06 for Evergreen

This inspection was carried out on 15th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 18/07/06

Evergreen 08/05/05

Evergreen 02/11/04

Evergreen 14/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Evergreen Cottage Place Bye Lane Copthorne West Sussex RH10 3LF Lead Inspector Mrs L Riddle Unannounced Inspection 12:30 15 February 2006 th Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 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 DS0000057956.V270613.R01.S.doc Version 5.0 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 DS0000057956.V270613.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Evergreen Address Cottage Place Bye Lane Copthorne West Sussex RH10 3LF 01342 719111 01273 508247 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) Independent Lifestyles Limited Post Vacant Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th May 2005 Brief Description of the Service: Evergreen is a care home registered to provide accommodation and personal care for two service users between the ages of eighteen and sixty-five years who have learning disabilities (LD) The registered provider is Independent Lifestyles Limited for whom Miss Donna Hawes is the responsible individual. The registered manager’s post is currently vacant but the acting manager has applied to the Commission to become registered and will undergo a fit person interview in the very near future. Evergreen is in Copthorne between the towns of Crawley and East Grinstead both of which have train stations, shops and other amenities. The home is a single storey building and the accommodation includes two single bedrooms and a spacious lounge/dining area. There are extensive grounds that can be easily accessed by the residents. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of three and a quarter hours by one inspector between the hours of 12:30 and 3:45 pm as part of the yearly inspection process. Prior to this inspection the previous inspection report was read along with other documents and correspondence relating to the home. Some records and documents were examined during this inspection and a tour of the premises was undertaken. Both residents were at home at the beginning of the inspection as it was half-term but one went out shopping and the other fell fast asleep as she had been unwell. They were not therefore spoken with on this occasion at any length. Two staff were on duty including the acting manager who was due to go off duty at 2 pm but who stayed to assist with the inspection. One of the two support workers took the one resident shopping and the second member of staff was available to look after the other resident. This support worker was spoken with and discussion took place with the acting manager. What the service does well: What has improved since the last inspection? Covers have been fitted to all but two radiators in the home and these were scheduled to be completed during the weekend following this inspection. Places have been reserved for two staff on a training course in Adult Protection. Further staff will be attending but the number of places available on each course is limited. The toilet seat in the WC has been mended and a new seat fitted to the WC in the bathroom. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 6 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. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 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 DS0000057956.V270613.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. They were found to be met in full when the last inspection was carried out. EVIDENCE: Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Resident’s assessed and changing needs are reflected in their care plans and they are able to make choices and decisions about their lives with assistance as needed. EVIDENCE: The two care plans were examined and found to be very comprehensive. A full review takes place annually but the plans are kept under constant review by staff on a daily basis and any changes recorded appropriately. Care notes, risk assessments, goal plans and activity sheets provide evidence of decisions, choice and risk taking. Much of the information in resident’s files is in pictorial format so that they can better understand it. A support worker was heard to be asking the residents what they wanted for their lunch. The residents can if they wish accompany staff on the food shopping trip to help select items. One went with a support staff during the inspection. The acting manager confirmed that residents choose what clothes they want to wear each day and go out with support staff to buy their own new clothing. Both residents are able to state what they do and do not want. Residents are able to take some risks in the course of their daily lives but these have all been assessed and recorded and residents are under close observation by staff. It was noted that they are able Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 10 to participate in such activities as swimming and horse riding where there are risks but safety precautions are built in to the risk assessments. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16, 17 Residents have opportunities for personal and educational development both within and outside of the home. Their rights are respected and meals and mealtimes are arranged in accordance with resident’s individual needs and preferences. EVIDENCE: Both residents have their personal activity programmes which have been arranged with their agreement and which are suited to their individual abilities and states of health. One resident has a number of health problems and her programme is mainly geared around activities in the home because of this. She may also enjoy shopping trips, lunch outings, horse riding and music sessions on her better days. The other resident has a full weekly programme which involves her in attending a day centre three times a week where she takes part in, for example, yoga and drama. She has personal shopping trips, food shopping and enjoys arts and crafts sessions as well as horse riding. A music therapist visits the home weekly to provide a session for both residents. Weekends are free but the acting manager said that these usually include trips out for one or both residents to cafes, places of interest or family visits. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 12 Residents have comfortable rooms with their own possessions around them and can spend time quietly and in private whenever they wish. Staff respect this and knock or ask permission before entering their rooms. It was observed that staff were spending time talking with the residents in the lounge and the resident who was well was being asked whether or not she wanted to go shopping after lunch. The menus are worked on a four weekly rotating basis. The acting manager said that she is planning to revise these as there is quite a lot of repetition from week to week and she wants more input from the residents. Residents have their main cooked meal in the early evening. One resident needs a special diet and it was evident that this is well catered for. Special items of food and ingredients are purchased and kept in a name-labelled cupboard to avoid any mistakes. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 The personal support needs of residents are addressed in accordance with their plans of care and the home has procedures in place for managing medication so that residents receive it regularly and as directed by their general practitioners. EVIDENCE: The care plans identify the levels of personal support needed by each resident and explain how it should be given in a way that is suitable and acceptable to the individual. Support with personal care such as dressing, washing and bathing is given in private. Times for getting up and going to bed are flexible and it was noted in the care plan that one of the residents quite often likes to get up late as elements of her illness can leave her feeling very tired. As previously mentioned, staff enable the residents to choose their own clothing and what they wish to wear each day. Additional specialist advice and support for the residents is provided by the Community Team for People with Learning Disabilities should either resident require such services as physiotherapy or speech therapy for example. They may also provide help or advice to staff on managing challenging behaviour and other problems if needed. Neither resident is able to manage or have control of her own medications due to the levels of disability. This is therefore in the control of the home and is stored in a locked cupboard. The receipt of medications brought into the home and administered to the residents was seen to be recorded appropriately and Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 14 records were up to date. The acting manager confirmed that records of disposal are maintained but the returns book was with the pharmacist at the time of inspection. It is signed as received by the pharmacist and returned when the next batch of medications are delivered. Whilst staff have received training from the pharmacist in the use of the monitored dosage system for drug administration, they have not had more in-depth training in the safe handling of medication. A recommendation is made in respect of this. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a clear complaints procedure which has been explained to the residents and is included in the Service User Guide. There are procedures in place to protect residents from all forms of abuse and training for staff is being arranged. EVIDENCE: The home has a clear complaints procedure which is also in pictorial format and has been explained to each resident. It is acknowledged that they may be unable to comprehend this fully due to their disabilities but both have close family relationships and people to act on their behalf. There is a facility to record complaints should any be received but none had been to date. The home has a copy of the West Sussex Procedures for the Protection of Vulnerable Adults and this is available for staff reference. Thorough recruitment checks are undertaken which helps to protect residents and the home has had cause in the past to refer a staff member onto the POVA (Protection of Vulnerable Adults) list. The member of staff spoken with knew that she has a responsibility to report if she witnesses bad practice. The acting manager said that she had obtained places for two staff on a training course which commences shortly and further staff will be undertaking this as places become available. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 There are toilet and bathroom facilities to meet the resident’s assessed needs and the home is clean and hygienic. EVIDENCE: The home provides a separate WC and a bathroom with a WC. One toilet seat had been mended and the other replaced since the previous inspection. The bath is fitted with an aid to assist the residents and there are also hand rails for this purpose. The home throughout was found to be clean and fresh and there are suitable domestic arrangements for laundering. Staff have had video training on infection control measures. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35, 36 Residents benefit from being supported by an effective staff team EVIDENCE: There are sufficient staff to provide one to one care for the residents between the hours of 8:00 am and 8:00 pm. Nights are covered by one awake person with other staff on call but not on the premises. Duty rotas examined confirmed these levels. Training records showed that staff had received training in managing challenging behaviour, dealing with epilepsy and in communication as well as other topics. The acting manager said that there are plans for her to undertake a ‘Training the Trainers’ course in manual handling so that she can cascade this down to the support staff team. Videos are used to train the staff in health and safety topics such as fire safety and basic first aid. One member of the support staff has a National Vocational Qualification (NVQ) at level 3 and the acting manager also has this. She is currently undertaking NVQ 4 and the Registered Managers Award. It was seen that a detailed individual training record is maintained for each member of staff. Four staff files were examined at random and found to contain all necessary documentation to show that robust recruitment procedures are followed. All staff receive statements of terms and conditions and copies of these were seen to be held in their individual files. Records seen and discussion with a member of the support staff confirmed that regular formal supervision is provided. She said that she finds this useful and beneficial to her work in the home. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41, 42 An effective quality assurance/monitoring system has not yet been developed which means that the home’s success in achieving its aims, objectives and statement of purpose cannot be properly measured. The home’s record keeping helps to safeguard the resident’s best interests and their health and safety is promoted and protected. EVIDENCE: There was no evidence to show that the home has an effective system in place for self-monitoring its performance. There appears to be no annual development plan for the home. The acting manager found one or two surveys which had been used to obtain comments from other professionals and relatives but these were not recent and there was nothing to show what if any action had been taken to quantify the results of these. The registered provider does carry out monthly monitoring visits to the home and reports in writing on these. Records examined such as care plans, resident information, staff files and those relating to finance, medication, fire safety, and accidents/incidents were well maintained, up to date and accurate. Personal information/ records are Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 19 stored securely and handled appropriately. All staff had been made aware in writing of the need for confidentiality. The home has a health and safety policy. Staff receive training and updates in health and safety related topics as previously mentioned. There are certificates and other documentation to show that equipment and installations such as electrics are tested at appropriate intervals. Risk assessments had been undertaken in relation to the premises as well as those for the individual residents. Records showed that the weekly fire bell tests are carried out and accidents and incidents recorded and where necessary reported. The bath is not fitted with a regulating valve to control the hot water temperature as one of the residents will not bath at the recommended temperature of 44 degrees centigrade as she finds this too cool. The environmental health officer has confirmed in a letter (seen) that this is acceptable as long as a risk assessment has been undertaken which was also seen to have been done. Both residents require staff presence and assistance to bath at all times. It is however recommended that a written bathing procedure be put in place to support the risk assessment. This should remind staff of the need to test the temperature of water before the immersion of residents and there should be an agreed limit on how hot the water can be to avoid the risk of scalding. Evergreen DS0000057956.V270613.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score N/A N/A N/A N/A N/A Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 N/A N/A Standard No 24 25 26 27 28 29 30 STAFFING Score N/A N/A N/A 3 N/A N/A 3 LIFESTYLES Standard No Score 11 N/A 12 3 13 N/A 14 N/A 15 N/A 16 3 17 Standard No 31 32 33 34 35 36 Score N/A N/A 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Evergreen Score 3 N/A 3 N/A Standard No 37 38 39 40 41 42 43 Score N/A N/A 2 N/A 3 3 N/A DS0000057956.V270613.R01.S.doc Version 5.0 Page 21 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. 1. Standard YA39 Regulation Requirement Timescale for action 31/05/06 24(1)(2)(3) The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the home. 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. 2 Refer to Standard YA20 YA42 Good Practice Recommendations Support staff who handle medication should receive more in-depth training. A written bathing procedure should be put in place to support the risk assessment in relation to hot water temperatures. 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