Inspection on 08/05/05 for Evergreen

This inspection was carried out on 8th May 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Evergreen 18/07/06

Evergreen 15/02/06

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 Annette Turner Unannounced 08 May 2005 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 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 Stationary 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 H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Evergreen Address Cottage Place, Bye Lane, Copthorne, West Sussex, RH10 3LF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01342 719111 Independent Lifestyles Limited Mrs Jane Burse CRH 2 Category(ies) of LD Learning disability - 2 registration, with number of places Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 02 November 2004 Brief Description of the Service: Evergreen is a care home registered to accommodate two service users between the ages of eighteen and sixty-five who have a learning disability (LD). Evergreen is in Copthorne near the town of Crawley. Evergreen is a single storey building with two single bedrooms and a lounge area that is also used as a dining room. There are extensive grounds that are accessible for service users. Independent Lifestyles Limited owns Evergreen. Miss Donna Hawes is the responsible individual for the company and Mrs Jane Burse is the registered manager responsible for the day-to-day running of the home. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Monday 2nd May and Sunday 8th May. The first visit was to check the activity programme for the two women living at Evergreen to make sure that the unannounced inspection would take place at a time when they were both at home. The visit took an hour and a half. Two care staff were on duty and one service user was at home. The unannounced inspection took place on a Sunday morning over three hours. Both women were at home and two care staff were on duty. A letter has been received from the provider regarding reducing the hours that the registered manager is in the home. During the unannounced inspection the newly appointed senior member of staff called in and stayed for half an hour. A tour of the building took place. During the two visits five staff were spoken with and records and policies were seen. One resident sat with the inspector and a member of staff to go through a pictorial comment card; she was able to indicate ‘yes’ and ‘no’ to the questions on the card. What the service does well: The women who live at Evergreen have a comfortable home that is well decorated. There are well kept grounds for them to use. Each person has a room of her own that is bright with personal items. During the day one member of staff spends time with each resident so that they can choose the activities they wish to do. The care staff said they enjoy their work and want to provide good care for the women. Both women were relaxed in their home and were comfortable with the care staff. The menus were varied and the mealtime was relaxed. The care staff said that the women go shopping with them for food so that they can choose the things they like to eat. The care plans, goal plans and risk assessments were detailed so that staff know what care they need to provide. There are behaviour guidelines so that residents can be helped when they are upset. The residents are encouraged to keep in touch with their families. One woman indicated that she gets on with the other person who lives at Evergreen. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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 H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 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 standard(s) 2, 3, 4 and 5 Residents are carefully assessed before they move to Evergreen. New residents have the opportunity to visit the home several times before they decide to stay at Evergreen so they can be sure their needs will be met. The care staff have the information they need to help them meet the needs of the residents. EVIDENCE: There is a thorough pre-assessment process that includes information from health and social care professionals who have worked with the residents. Records showed that one person had made several visits to the home with her relatives before she moved in. The care staff said that they understood the needs of the two women. The staff had been given some training to help them. Records showed that both women have support from specialist services for people who have a learning disability. There were copies of the contracts for the residents; these were in symbol format to help them understand what they can expect from their stay at Evergreen. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 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 standard(s) 6, 9, 10 The care planning process is thorough and staff are provided with the information that they need to make sure the residents are well cared for. The women have been supported to set their personal goals with the help of others who know them. Guidelines for managing challenging behaviour have been provided so that staff know how to protect residents from harm. Care staff should understand what to do if a resident falls and is unable to get up without assistance. EVIDENCE: The care plans, goal plans and risk assessments were detailed. The records included guidance for staff about health, personal and social care needs. One of the women had been able to sign her agreement to the care plan. The care staff said they knew about the care that each woman needs and what they need to do each day. One person was not sure what to do if a resident fell and could not get up unaided. The staff record the daily progress of the women towards reaching their personal goals. There is written guidance about how to record information. There were detailed records of community care reviews and some evidence to show that the women are helped to review their progress. A parent’s views had been taken into account during one review. Risk assessments had been Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 10 carried out so that the residents can be supported to take risks as part of developing their independence. One restriction to choice for health reasons was noted. Care staff were clear that they should not discuss the residents’ welfare with anyone outside the home. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 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 standard(s) 11, 13, 14, 15 and 17 The women who live at Evergreen have opportunities to take part in activities at home and in the community. The residents are supported to have contact with their relatives. The residents are provided with food that is varied with fresh fruit and vegetables daily. People with special dietary needs are catered for. EVIDENCE: Each resident has an activity programme. One of the women indicated that she enjoys the activities. The women have the opportunity to go out shopping, horse riding and visiting places of interest. During the day there is one member of staff for each resident so that they can take part in different activities. Not all care staff are able to drive. One person attends drama and other activities at a local day centre. There are books and puzzles at home that one person is able to enjoy. There is music and television available in the home. On both days one service user was either with her family or due to go out with her family. There was a list of home visits due for one resident. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 12 There were four weekly menus that were varied. Not all the food in the fridge was dated and labelled to ensure that only fresh food is provided. The mealtime was relaxed. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 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 standard(s) 18, 19 and 20 It was evident that the personal and healthcare needs of residents are being monitored. There was clear guidance for staff to make sure they know what care is to be provided. EVIDENCE: The case records had detailed information about the physical and emotional care needs of residents. There was information about diagnosed medical conditions and what staff need to do to support the residents with their health. There were medical appointments noted in the case records. There were charts to record weights however these had not been filled in for several months because the scales are not working. A parent’s views had been taken into account over a medical issue. Health professionals from the local specialist team are providing support to the women. The medication storage and recording systems were clear. Neither of the women is able to administer their own medication. Records showed that medication reviews take place and that staff monitor the resident’s health. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 23 There are policies and training opportunities in place to ensure that residents are kept safe. It was not clear that all staff understand what to do in the event of an allegation of abuse. EVIDENCE: There are policies in place regarding adult protection and whistle blowing. There is a training video about adult abuse and some staff have been on courses about adult protection. It was not clear that all staff understand what to do if there are concerns that abuse may have occurred. Staff said that there are body maps to fill in when bruising is noted to make sure that these are recorded when accidents occur. Specialist advice is available in order to protect residents from self-harm. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 Evergreen provides a comfortable, homely environment for residents. The bedrooms suit their individual needs and promote resident’s independence by reflecting their individual taste and interests. The shared bathroom has adaptations to assist residents and keep them safe. The lounge and dining area is comfortable and is used by both residents. The home was clean and hygienic. EVIDENCE: Evergreen is well decorated with well-maintained grounds. The advice of the Environmental Health Officer has been sought regarding hot water valves. These have been fitted in the residents’ rooms but not in the communal bathroom. One resident was able to indicate that she is happy with her room. The toilet seat in the bathroom was broken and the seat in the separate toilet was loose; this requires urgent attention to prevent the women falling. One resident has had an occupational therapy assessment and rails have now been fitted in the bathroom to keep her safe. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, and 35 The residents have one to one staff cover during the day to ensure that their needs are met. The care staff were very committed to providing a good quality of life for the women. The training programme is being developed and is not comprehensive and must include the actions to be taken in the event of an accident or adult protection issue. The registered manager is available to provide support to staff and residents. EVIDENCE: The staffing rota showed that there are two care staff on duty during the day and one person on waking duty from eight in the evening until eight in the morning. One of the care staff working during the day was also covering night duty. The newly appointed senior member of staff said that she works for sixteen hours each week to provide guidance, supervision and training for staff. She also said that she has a full time job in another care home. There were training records to show that some training is planned to make sure that staff have the skills to provide care for the residents. Not all care staff were clear about adult protection procedures or manual handling. There will be some training available in working with people who have a learning disability. One member of staff has an NVQ level three award, one has NVQ level two and two staff are due to start in May. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 41 and 42 The policies and records are in place to ensure that the rights and best interests of residents are protected. The advice of the Environmental Health Officer regarding safety valves on hot water taps and radiator temperatures has been sought and risk assessments carried out. Radiator covers have not yet been provided to ensure the surface temperatures do not exceed 45 degrees centigrade. EVIDENCE: There is a comprehensive set of policies to provide guidance to staff and to protect residents. The recording systems are clear. There is written guidance for staff about recording to make sure that the progress of residents is documented. There is information and some training about health and safety to make sure the residents are kept safe. Fire records are kept up to date and fire drills take place to make sure everyone is protected. The radiator in the lounge was on and was very hot to the touch. The water in the bathroom taps was extremely hot. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 18 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 x 3 3 3 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 3 Standard No 11 12 13 14 15 16 17 3 x 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Evergreen Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x 3 3 3 x H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last inspection? 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 42 Regulation 13 Requirement The registered persons must ensure that radiator surfaces are guarded or have low surface temperatures in order to protect the health and welfare of residents. (Previous timescale of 31st October 2004 not met). Timescale for action 30th June 2005 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 23 Good Practice Recommendations The registered persons should ensure that all staff understand what should be done in the event of a concern that adult abuse may have occurred. Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 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. Extracts may not be used or reproduced without the express permission of CSCI Evergreen H60-H11 S57956 Evergreen V220381 040505 Stage 4.doc Version 1.30 Page 21 - 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. 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