CARE HOMES FOR OLDER PEOPLE
Evendine House Evendine Lane Colwall Malvern Worcestershire WR13 6DT Lead Inspector
Wendy Barrett Unannounced Inspection 20th December 2005 10:00 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 Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 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. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Evendine House Address Evendine Lane Colwall Malvern Worcestershire WR13 6DT 01684 540225 01684 541963 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) S B Residential Care Limited Anna Catherine Chapman Care Home 20 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (20), Physical disability over 65 years of age (2) Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: Evendine is located on the edge of Colwall, a village located in a rural area between Malvern and Ledbury. The home is set in well maintained gardens that are easily accessible to the residents. There are extensive views of the Malvern Hills and surrounding countryside. There are 20 registered places. All these places are registered for people over 65 years of age who have care needs arising from the usual ageing process. 6 of the places may be used for people over 65 years of age who have care needs arising from a mental disorder. A further 6 of the 20 places may be used to accommodate people over 65 years of age who have care needs arising from dementia. The accommodation is on two floors with access by a chair lift to the first floor. There are 19 bedrooms, one of which is for 2 people who wish to live together. 17 of the bedrooms have en-suite facilities. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place between 10am and 3pm. The Care Manager was at work in the home. Mrs. Bate arrived during the visit and assisted with some parts of the inspection. The inspection focused on key National Minimum Standards that were not scored last time. The report of the last inspection should be referenced to obtain a more comprehensive picture of the service. There were no requirements arising from the last inspection but action taken in response to two recommendations is described in the main body of this report. Five residents were interviewed and others were seen around the home. A sample of records and documentation maintained at the home was inspected. What the service does well: What has improved since the last inspection?
The Provider has completed the upgrading of the laundry facility by replacing the floor covering. There is a new arrangement for keeping a separate record of minor concerns raised by residents. Over a period of time this record will help the Providers identify any aspects of the service that may need to be improved. Senior staff have spent a lot of time reviewing the medication records they keep at the home and satisfying themselves that the records give them all the information they are likely to need.
Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 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. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 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 Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected this time. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Residents’ receive the support they need to deal with any personal or health care needs that arise. Other health care professionals are consulted as part of this work. EVIDENCE: A sample of care plans was inspected. The plans are very well written e.g. background information about specific physical conditions, clear and specific action plans for staff to follow, attention to the individuality of each resident. There is an effective review programme to ensure that the plans are always up to date. Residents who were interviewed gave examples of attention to their health care e.g. regular exercise sessions at the home, recent visits from G.P., routine dental and chiropody care. They were happy with the way they are supported when they have any health problems. Observation of residents who rely on staff to help them with their dress and appearance indicated good attention to this work e.g. hair and nail care, well laundered clothing. A sampled care record included details of regular review of skin condition by using a recognised assessment tool (Waterlow), a visit from a specialist Social Worker to help with sight disability, recent ‘flu vaccination.
Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 10 There is a robust approach to the management of medication although staff remain responsive to ideas for improving current practice e.g. Senior staff have recently been reviewing their system of recording the movement of medication through the home to ensure there is a clearly identifiable audit trail. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Residents can maintain contact with their families and friends as they wish. When additional support is needed, the staff provide this in a flexible way with regard to individual preferences. EVIDENCE: The Visitor’s book, kept in the entrance hall, showed a regular number of people visiting the home e.g. 9 visitors signed the book one day. A resident spoke about a visit from her daughter the previous day and confirmed that she can receive visitors in private whenever she wishes. There were also examples of residents being taken out by their families – ‘I may go my grandson’s over Christmas – it depends how I feel’. Some residents had recently been late night shopping with staff. One resident appreciated clothes and shoe sales held at the home from time to time. The care record of a resident who has no close family referred to various efforts by staff to provide some additional support e.g. advocacy service, Pets for Therapy. The local vicar had visited the gentleman. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The Commission has not received any complaints about the service since the last inspection. The Provider has responded to a recommendation arising from the last inspection by introducing a system of recording minor concerns. This supplements an existing procedure for recording concerns on daily progress reports for individual residents. The new record will help identify if particular aspects of the service are most likely to create minor difficulties and, therefore, may need review. It’s introduction will contribute to the quality monitoring system already in place. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The home is very well maintained with a high standard of décor, furnishings and fittings throughout. It was clean and warm at the time of this inspection. The laundry room floor was due to be replaced at the time of the last inspection. This work has been completed to provide an impermeable surface. The laundry room has now been fully upgraded, with new equipment, wall redecoration and the new floor covering. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The selection of new staff is a thorough process to ensure that the residents are protected and supported at all times. EVIDENCE: There were enough staff, including the Care Manager, to respond to the needs of the eighteen residents at the time of the inspection. The process for selecting new staff was inspected. Two recent examples of recruitment were looked at. The employment of a staff member from abroad had been managed through a Training Academy that specialises in this work. Records at the home identified a thorough system of vetting the suitability of the employee through checks made in their home country. Copies of relevant documentation e.g. police check, had been supplied to Evendine. The staff member had been provided with four weeks of induction training before being placed at Evendine. Records of this programme indicated a thorough and appropriate programme e.g. statutory health and safety training, a full day’s training on Protection of Vulnerable Adults legislation and recognised good practice. The second sampled recruitment file related to the employment of a local person with previous experience of similar work. The documentation reflected a satisfactory process. Efforts to obtain a reference from the last employer, another care Provider, had been unsuccessful and an assessment of suitability had to be made without this important part of the recruitment process. The Provider considered the overall strength of the application and assessed the applicant suitable. This is the appropriate way to deal with recruitment when previous employers do not respond to requests for references. When this type of risk assessment has to be made it is important to maintain a record of the steps taken in reaching a decision based on potential risk.
Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Residents’ financial interests are safeguarded, with good systems of accountability for money and valuables held by the Providers and consultation with representatives when this is necessary. EVIDENCE: The Care Manager has almost completed her work on a Registered Manager’s Award. The Providers have already obtained this qualification. The Provider’s Statement of Purpose refers to a ‘Policy of continual evaluation’. Evidence of its implementation was seen at the home. This included feedback on the quality of the service from residents, relatives and involved professionals. The documentation was extensive and addressed all aspects of the service. The Provider confirmed that the file is available to interested parties on request. The outcomes of each evaluation exercise should be summarised into a short report to clarify how far previous objectives have been met and what objectives for the service have been identified for the future. This would provide residents, relatives and the Commission a readily accessible picture of review outcomes.
Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 16 The Providers do not act as agents for any residents. Some residents have small amounts of spending money in the safekeeping of the Providers. Where this is the case, storage arrangements are secure and records maintained to account for transactions. A sample of money held for one resident showed a correct balance on the relevant money record sheet. In order to strengthen the security of personal money held in safekeeping access is restricted to three named staff. There is insurance in place to cover money and valuables held by the Providers and separate insurance for those held by residents in their rooms. A resident and family representative had been appropriately consulted in making an assessment of the resident’s ability to have a key for a lockable storage area in her bedroom. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 17 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x x x Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations The outcomes of quality monitoring exercises should periodically (e.g. annually) be summarised in a brief report. This would provide residents, relatives and the Commission with an overall picture of the service e.g. how many previously identified objectives have been met, what objectives have been identified for development of the service in the future. Evendine House DS0000024707.V274381.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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