Inspection on 18/12/07 for Evelyn May House

This inspection was carried out on 18th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Evelyn May House 15/12/08

Evelyn May House 10/01/07

Evelyn May House 18/10/05

Evelyn May House 03/05/05

Evelyn May House 21/02/05

Evelyn May House 09/08/04

Evelyn May House 25/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Evelyn May House Florence Way Langdon Hills Basildon Essex SS16 6AJ Lead Inspector Michelle Love Unannounced Inspection 18th December 2007 09:15 X10015.doc Version 1.40 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 Evelyn May House DS0000044401.V353685.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 Older People. 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. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evelyn May House Address Florence Way Langdon Hills Basildon Essex SS16 6AJ 01268 418683 01268 543952 evelyn.may@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc 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) Ms Rumbidzai Mercy Mahupete Care Home 59 Category(ies) of Dementia - over 65 years of age (41), Old age, registration, with number not falling within any other category (37) of places Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The number of service users for whom personal care is to be provided shall not exceed 59 (total number not to exceed fifty nine). Personal care may be provided for up to 37 older people over the age of 65 (total not to exceed thirty seven). Ground and first floor accommodation to be provided to 37 older people, of whom up to 19 may have dementia care needs. Second floor accommodation to be provided to 22 older people with dementia care needs. Personal care to be provided to no more than 41 service users with dementia over the age of 65 years and 1 service user under the age of 65 (details of this service user are known to the CSCI). (Total not to exceed forty one). 10th January 2007 Date of last inspection Brief Description of the Service: Evelyn May is a purpose built establishment providing care for up to 59 older people. The registration category permits the home to provide care for those people who have a formal diagnosis of dementia. The home has three floors and each floor is unitised. All bedrooms are for single occupancy and have en suite facilities. Each floor has bathrooms, toilets and lounge/dining areas. The home is situated in the Langdon Hills area of Basildon and is in reasonable distance to/from local community services and amenities. The home has a large adjacent car park. There is limited garden/patio areas surrounding the home. Evelyn May has a statement of purpose and service users guide available. Information about the home and most recent inspection report are available to residents/visitors in the lobby area of the home. Copies of the homes Service Users Guide were also provided in many of the bedrooms around the home The weekly fees are £425.95 to £476.28 for those people funded by a local authority and £590.00 for a private placement. There are additional charges for chiropody, hairdressing, personal items and newspapers/magazines. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. The visit took place over a 10-hour period and all of the key standards and the manager’s progress against previous requirements from the last inspection were inspected. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment, detailing what they do well, what could be done better and what needs improving. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Following the inspection, relatives were contacted so as to seek their views about the services provided and 7 surveys were returned to the Commission for Social Care Inspection. Additionally 3 staff surveys were also forwarded and received. The deputy manager, operations manager and other members of the staff team assisted the inspector. Feedback on the inspection findings were given throughout the day and summarised at the end of the day. The opportunity for discussion and/or clarification was given. What the service does well: Residents were seen to be relaxed and well cared for. Staff, were observed to be knowledgeable and understanding of individual residents’ needs and to have a good rapport with them. The management of the home have an appropriate system in place for assessing the needs of prospective people who wish to live at the care home. Sufficient information depicting the services and facilities provided at Evelyn May are readily available and accessible for residents, relatives and other interested parties. Residents are actively encouraged and enabled to participate in a range of activities, which meet their social care needs. Visitors to the home are made to feel welcome. Comments relating to food were positive. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A system is in place to ensure that prospective residents are properly assessed prior to admission and this helps to ensure that the staff team are able to meet people’s needs. EVIDENCE: A copy of the Statement of Purpose and Service Users Guide was available in the main reception area and contained the latest inspection report. Relative’s surveys showed that people felt that they had sufficient information about the home and services provided. Two files were examined for those people recently admitted to Evelyn May. Records showed that a pre admission assessment had been completed prior to admission, to ensure that the staff team of the home were able to meet the prospective residents care needs. The assessment was observed to be detailed and covering all the required areas. Additional information had also been Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 9 provided by individuals placing authority and one resident’s previous care home. There was evidence, depicting involvement within the pre admission assessment process by both residents and their representatives. The home does not provide intermediate care. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst resident’s health and care needs were identified and planned for, other shortfalls in care planning and medication practices could adversely affect outcomes for residents and their wellbeing. EVIDENCE: As part of this inspection a random sample of care files were examined. Information recorded overall, was seen to be completed well and provided a good level of detail within several areas. Discussion with individual members of staff indicated that staff had a good knowledge and understanding of residents care needs. Interaction between staff and residents was seen to be appropriate and staff, were noted to be respectful, friendly and genuine towards residents. Care records show that further development of the care planning and risk assessment processes is needed and these were discussed with both the deputy manager and operations manager at the time of the inspection. Staff, Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 11 need to ensure that individual resident’s needs are fully recorded, and include the interventions required so as to ensure the appropriate delivery of care. Particular attention must be afforded to those people who have a diagnosis of dementia/deteriorating mental health and the care plan must include details of how this affects their daily living activities and specific interventions required by care staff to manage this proactively. Additional information is required identifying individuals strengths and abilities so as to promote individual resident’s self worth and ensure that existing skills are maintained. One relative survey returned to the Commission recorded that they felt that staff struggled to meet their relatives care needs as a result of their ethnicity. The survey detailed that areas of concern had been discussed with the management of the home, however they felt that improvements were relatively short lived. Since the last inspection it was positive to note that behavioural charts for individual residents had been introduced so as to record behaviours exhibited, actual care delivery by care staff/outcomes and to detect possible trends and/or common themes. It was disappointing to note that behavioural charts were not completed for all residents who exhibited challenging behaviour and information detailed within daily care records was not always transferred or cross referenced to the behavioural record. Care records detailed that restraint/break away techniques had been applied by staff in dealing with a resident’s behaviour, however no record was available depicting the type of physical restraint used, the duration of the restraint used and staff involved. This needs to be reviewed with appropriate records maintained. Additionally where restrictions are imposed on individual residents’ choice and freedom, further work is required to ensure that there is clear information depicting agreement between the home and the resident and that where appropriate other interested parties have also been consulted e.g. resident’s family and/or placing authority. Formal risk assessments were completed for all residents in relation to falls, manual handling and nutrition and these were seen to be detailed and comprehensive. Risk assessments for specific areas of assessed risk, were generally observed to be completed for most aspects, however gaps were noted whereby risk management strategies detailing staff interventions pertaining to aggression were not always recorded. The deputy manager was advised that risk assessments/strategies are important so as to ensure staff, are clear about what actions to take to minimise identified risks for individual residents. Records showed that residents have access to a range of healthcare services and professionals such as GP, Optician, Dentist, District Nurse Services, Community Psychiatry Nurse as and when required. Residents spoken with confirmed that they receive appropriate help with their healthcare needs. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 12 Daily care records were observed to be informative and detailed in most cases, however further development is required to ensure that records include staff interventions so as to evidence actual care delivery by staff to individual people. The Annual Quality Assurance Assessment detailed that within the next 12 months it is hoped that more staff will receive training relating to person centred care. The majority of medication is managed through a monitored dosage system (blister pack). The medication round was observed on one unit and staff practices were seen to be appropriate and in line with regulation. Medication was observed to be safely stored. The medication policy had been updated since the last inspection and this was readily available and accessible for staff and included a copy of the Royal Pharmaceutical Guidelines for the Administration and Control of Medicines in Care Homes. Records indicated that medication care plans/profiles are completed for those people who are prescribed PRN (as and when required) medication and for those who are prescribed creams. Where these are in place these were seen to be detailed and informative and there was clear information depicting treatment and outcomes. Additional information was recorded detailing changes to individual’s care needs. However, shortfalls were identified for those people who require a medication care plan/profile to be in place. For example where Medication Administration Records (MAR) recorded that some residents were consistently refusing medication, there was little and/or no information recorded as to how, this was being monitored by staff, and what proactive management arrangements where in place to liaise with healthcare professionals. When cross-referenced with individual’s care plans no information was recorded detailing staff’s interventions. Following the inspection, issues as described above were discussed with a specialist pharmacist inspector. The advice is that the management of the home should consider reviewing the above procedures and not to look at medication in isolation but as part of the actual delivery of care. Additionally some MAR records indicated that residents were receiving medication as PRN, however this was not being administered in line with the prescriber’s instructions. The deputy manager was, advised that this practice needs to be monitored and reviewed to ensure residents wellbeing. It was positive to note that where medication is covertly administered to residents, this is explicitly recorded within individuals care plans and includes, evidence of consultation and agreement by the person’s GP and their family. At the time of the inspection a copy of the training matrix for staff was requested. This was examined following the inspection, however this does not evidence when medication training was last undertaken for those staff deemed competent to administer medication to residents. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities programme at the home meets the social care needs of those people living at the care home. Residents receive a good diet. EVIDENCE: At the time of the inspection, it was noted that currently there is one activities co-ordinator available within the home and they are employed for 37 hours per week, Monday to Friday. The inspector was advised by the operations manager that efforts are being made to recruit another activities co-ordinator for a further 18 hours per week. The activities co-ordinator expressed that although her hours are primarily Monday to Friday, these are flexible so that on occasions evenings/weekends are also covered. The activities co-ordinator was observed to have a good relationship and rapport with individual residents and they were observed to be responsive to her encouragement and instruction. Additionally this member of staff was noted to have a good understanding and knowledge of individual resident’s social care needs. The inspector was advised that a weekly activities roster is devised and implemented. This was observed to be displayed in the main reception area Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 14 and within each unit. Consideration should be given to providing this in both a written (larger print) and pictorial format so as to enable residents to make an informed choice. On inspection of the activities roster for four weeks this evidenced activities, such as church, club 100, board games, arts and crafts, quiz, gentle exercise, reminiscence, bingo, cards, 1-1 sessions, health and beauty sessions and occasional pub outings. The activities co-ordinator was advised to consider other activities such as enabling individuals to assist/get involved with day to day tasks around the care home (laying the table, folding napkins, making a bed etc) so that individuals may gain a level of satisfaction, achievement and self worth. Additionally staff could consider putting together a memory box and/or life story-book for individual residents, which may help with drawing out memories and aid communication. Of those residents spoken with, positive comments were made in relation to the activities provided. Further consideration should be undertaken by the management of the home to encourage care staff to take a more active role in undertaking activities with residents. This was also highlighted within the Annual Quality Assurance Assessment. The activities co-ordinator confirmed they had completed an 8 week dementia course and this had included specific information relating to activities. The inspector was also advised that sensory equipment has been purchased and in the New Year a sensory room is to be newly created for residents use. Sensory alcoves have been created on the dementia unit. The management team operate a four week menu. This was observed to offer residents a varied diet and included two options of main meal at lunchtime and teatime and a cooked breakfast available three times a week. The lunchtime meal was observed within one unit (Bluebell). It was positive to note that dining tables were attractively laid and condiments and drinks were readily accessible for residents. The lunchtime meal was observed to look plentiful and appetising and residents spoken with were positive about the food provided. It was equally positive to note that residents were offered second helpings and alternatives to the menu were readily available. The lunchtime experience for residents was observed to be calm and relaxed, with appropriate care provided to those people who require assistance to eat their meal. Visiting at the home is open and many visitors were observed to come and go throughout the day. Staff, were observed to have a good relationship and rapport with visitors. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents are protected from abuse, shortfalls were noted with regard to complaint management and this does not ensure positive outcomes for residents and other interested parties. EVIDENCE: Evelyn May has a clear complaints policy and procedure in place and this was observed to be displayed for all interested parties. The management teams complaint file showed that since the last key inspection there have been 7 complaints. Records indicated that in some cases insufficient information was readily available depicting details of the actual complaint, investigation and action taken. Both the deputy manager and operations manager were advised that this needs to be reviewed. It was positive to note that the management of the home had received a number of `Thank You` cards and letters of compliment about the care/services provided at Evelyn May. Of those relative surveys received, all but one indicated that they know how to make a complaint. No safeguarding issues have been highlighted since the last inspection. The management of the home have appropriate policies and procedures in place, which are accessible and readily available for staff. Staff spoken with demonstrated a good understanding and awareness of safeguarding procedures. The training matrix for staff evidenced that the majority of staff Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 16 have attained training relating to safeguarding. Where there are gaps, the deputy manager was advised to ensure that this is provided as soon as possible. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Evelyn May provides a clean, comfortable and safe environment for residents, which meets their needs. EVIDENCE: Evelyn May is a purpose built home that presents as homely and comfortable for residents use. The home is set out on three floors and each floor operates as a separate unit, providing care for a set group of residents. On the day of inspection the home was observed to be clean, odour free and no health and safety issues were highlighted. Appropriate signage and picture recognition were available throughout the home to aid orientation for residents within Evelyn May. A partial tour of the premises was undertaken and of those individual residents bedrooms inspected, all were seen to be individualised and personalised. The Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 18 communal areas were decorated with Christmas decorations and the main reception area was observed to be welcoming. Comments from residents about the home environment were positive. A random sample of safety and maintenance certificates showed that equipment and services in the home were kept in good order. The deputy manager and operations manager were advised that the electrical safety certificate was undecipherable and it was unclear as to whether or not this was satisfactory. The operations manager advised that a copy would be forwarded to the inspector, however the one held at head office is also unclear. Water temperatures were checked at random throughout the home and were found to be satisfactory and within acceptable guidelines. The home has a fire safety risk assessment in place and all other fire safety records were seen to be in order. The Annual Quality Assurance Assessment details that in the next 12 months it is planned for a sensory garden to be established, for themed lounges to be newly created and for new furniture to be acquired. The Annual Quality Assurance Assessment details 11 members of staff have received training relating to the prevention of infection and management of infection control. The staff, training matrix also details that the majority of staff have received training relating to health and safety and fire awareness. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The level of staffing on occasions may restrict the ability of the service to deliver person centred care and to ensure that residents needs, can be met and that they are safe. Recruitment procedures do not fully protect residents. EVIDENCE: The deputy manager advised the inspector that the home’s staffing levels remain at 1 care team manager per unit and 2 carers (Bluebell), 3 carers (Rose) and 2 carers (Camellia) between 07.00 a.m. and 22.00 p.m. and at night there is 1 care team manager and 2 carers (Bluebell), 1 carer (Camellia) and 2 carers (Rose) between 22.00 p.m. and 07.00 a.m. each day. In addition to the above a chef is employed between 08.00 a.m. to 16.00 p.m. and a kitchen assistant between 08.00 a.m. and 13.00 p.m. daily. Housekeeping hours are between 15-18 hours in total per day and a maintenance person is employed to cover Evelyn May Monday to Wednesday, however this is flexible. The deputy manager’s hours are supernumerary to the above. The inspector was advised that current vacancies are for 1 full time care assistant, 1 care team manager and 1 night care assistant (22 hours). Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 20 On inspection of four weeks staff rosters, it was evident that staffing levels as detailed above have generally been maintained, however there are occasions when the above staffing levels have not been met and no Regulation 37 notifications have been received by us detailing a reduction in staffing levels and measures undertaken by staff to deploy additional staff to the care home to meet residents needs. Additionally the rosters also indicate that some staff had been working a lot of hours in one week e.g. 67-75.5 hours. The management of the home need to monitor the above so as to ensure that staff, remain competent and able to perform their role so as to safeguard residents wellbeing. One staff survey provided to CSCI confirmed that staff, are on occasions working excessive hours and there are times when the home is short staffed and agency cover is not always agreed. The Annual Quality Assurance Assessment details that within the next 12 months it is hoped that a more robust pool of bank staff will be established. This is seen as positive and may assist to address the above issues. Staff recruitment files for four newly employed members of staff were examined. Shortfalls were identified whereby not all records as required by regulation were available and this related to only one written reference for one person and no photograph or record of a Criminal Record Bureau check for one person. Additionally the file for another person only contained their completed application form and health declaration; with no other records available. Initially the deputy manager was unable to advise as to why there were limited records available, however he was able to ascertain later in the day that the person’s records were held at head office and had not been forwarded to the care home. Induction records were incomplete and/or not evident for some people and of those records available, these were not in line with Skills for Care. The deputy manager was advised that current recruitment practices do not adequately support or protect residents and need to be reviewed. A copy of the staff, training plan was provided for the inspector and this was examined following the site visit. The training plan evidences that this was updated on 9/12/07 and indicates that staff have up to date training relating to safeguarding, first aid, moving and handling, health and safety, food hygiene and fire awareness. The training plan does not provide evidence of those courses undertaken which are associated with the needs of older people. The Annual Quality Assurance Assessment details that more specialist training pertaining to wound/simple dressing management, understanding mental health and Parkinson’s disease is required. The inspector was advised by the deputy manager that 18 members of staff have completed NVQ Level 2 and 3 staff have completed NVQ Level 3. At this time 8 members of staff are completing NVQ Level 2 and 2 are undertaking NVQ Level 3. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst management arrangements are generally sound, the shortfalls identified could adversely affect outcomes for residents. EVIDENCE: At the time of the inspection, the registered manager was not available as on maternity leave. Currently the home is being managed by the deputy manager with additional support provided by the operations manager. Although there are some areas as highlighted within the main text of the report, which are good and evidence appropriate management, there are some Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 22 areas, which continue to require, further development and these refer specifically to some aspects of care planning/risk assessment, medication, staff recruitment, staff training for those conditions associated with the needs of older people and complaint management. The deputy manager has worked at Evelyn May since the beginning of November 2007 and advised that he has worked within a care setting for the past 5 years. He has recently completed NVQ Level 4 and has commenced the Registered Managers Award. Staff surveys indicated that staff, feel supported by the management of the home and comments from residents and relatives were equally positive. Comments received included “ They appear to be sensitive to my relatives needs and wants”, “My relative says that everyone is so kind and looks after their wellbeing. They look 10 years younger and are much more mobile” and “I am very pleased with the care that my relative is getting. This is a very helpful and friendly home”. The inspector was advised that a quality assurance audit was undertaken in July 2007 and an annual audit report completed. Following this audit an action plan was devised and also cross-referenced with those requirements as highlighted from the last CSCI inspection report. The home holds monies on behalf of residents and records are maintained in the home. On inspection of a random sample of individual resident’s monies, the majority were found to be in order with receipts available, however the monetary records for one person were inaccurate and there was no evidence as to why there was a discrepancy. This was not resolved at the time of the site visit, however the operations manager investigated further and advised the inspector that invoice/monies had been located and this accounted for the variance. The operations manager confirmed that accounting procedures in line with Runwood policies and procedures had not been adopted and complied with. The home has a health and safety policy and procedure. Resident accident records were observed to be well maintained and information recorded satisfactory. On inspection of a random sample of staff files, these evidenced that staff at the care home are receiving regular formal supervision. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 3 X 3 Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement Ensure that care plans are developed further so that these are person centred and fully reflect individual resident’s care needs. Previous requirement of 30.05.06 and 1.3.07 not fully met. Ensure that risk assessments are devised for all areas of assessed risk so that these can be minimised and ensure residents wellbeing and safety. Ensure that a record of any restraint used on a resident is clearly recorded so as to evidence actual support/care provided. Ensure that the healthcare needs of individual residents are clearly recorded/identified and depict staff interventions so that the delivery of care for people meets their needs. Ensure that information relating to individuals medication is sufficient so as to determine actual care/support provided to DS0000044401.V353685.R01.S.doc Timescale for action 18/12/07 2. OP7 13(4) 18/12/07 3. OP7 17(1)(a), Schedule 3 (p) 12(1)(a) 18/12/07 4. OP8 18/12/07 5. OP9 12(1)(a) and (b) 18/12/07 Evelyn May House Version 5.2 Page 25 6. OP9 12(1)(a) 7. OP16 22 8. OP27 18 9. OP29 19 10. OP35 17(2), Schedule 4 (9) individual residents and where appropriate ensure that healthcare professionals/services are contacted. Ensure that prescribed medication is administered as per the prescriber’s instructions so as to ensure residents safety and wellbeing. Ensure that complaints are managed appropriately and that records include evidence of the actual complaint, investigation, action taken and outcome. Ensure that at all times there are suitably qualified and competent staff on duty in sufficient numbers as appropriate to meet the needs of residents. Ensure that robust recruitment procedures are adopted at all times for the safety and wellbeing of residents. Ensure that there are clear records to depict money deposited/received/expenditure for individual residents. 18/12/07 14/02/08 18/12/07 18/12/07 18/12/07 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. 3. Refer to Standard OP7 OP12 OP29 Good Practice Recommendations Daily care records should include information depicting staff interventions and delivery of care. Consider devising the activities programme in larger print and/or pictorial so as to enable residents to make an informed choice. Ensure that new staff receive an induction which is in line with Skills for Care. Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. Extracts may not be used or reproduced without the express permission of CSCI Evelyn May House DS0000044401.V353685.R01.S.doc Version 5.2 Page 27 - 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. 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