Inspection on 22/02/07 for Evendine House

This inspection was carried out on 22nd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Evendine House 21/05/08

Evendine House 20/12/05

Evendine House 31/08/05

Evendine House 01/12/04

Evendine House 17/06/04

Evendine House 28/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Evendine House Evendine Lane Colwall Malvern Worcestershire WR13 6DT Lead Inspector Wendy Barrett Unannounced Inspection 22nd February 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 Evendine House DS0000024707.V331498.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. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evendine House Address Evendine Lane Colwall Malvern Worcestershire WR13 6DT 01684 540225 F/P 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.V331498.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 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. All potential or new residents receive an information pack that describes the service they can expect to receive. Brochures are also displayed in the main entrance hall at the home. In January 2007 the fees ranged from £420 per week to £450 per week. There are additional charges for hairdressing, chiropody, transport, newspapers and magazines and toiletries. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written with reference to information about the service and held by the Commission, a pre-inspection questionnaire completed by the Provider, survey responses from residents, relatives and visiting professionals, and an unannounced inspection visit to the service. What the service does well: What has improved since the last inspection? The premises have been subject to various improvements since the last inspection e.g. two bedrooms have had en-suite facilities added, a large bathroom has been added so that staff have plenty of room to help residents bathe. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Evendine House DS0000024707.V331498.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 Evendine House DS0000024707.V331498.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): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to decide if the home will suit them. They are asked about their needs and wishes before they are admitted so that the staff will know how to work with them. EVIDENCE: Every resident receives an information pack that fully describes the type of service offered at the home. The details are regularly revised to be sure they are up to date. In addition, every resident receives a contract of residence. Signed and dated examples were available during the inspection visit. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 9 Before the home agrees to admit a new resident one of the Providers visits the potential resident and finds out exactly what care they need and how they want to live. There are records of this work and these reflect thorough attention e.g. possible risk areas are assessed. An initial care plan is then written, based on the findings of the assessment. This tells the staff how to go about their work with the new resident. Residents described a gradual introduction with plenty of opportunity to see the accommodation and experience everyday life at the home –‘my daughter came in a few times, and although usually without an appointment, was well received and shown around – including kitchen etc.’, ‘I spent a month at the home to experience what it was like’. Evendine House DS0000024707.V331498.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to maintain their independence but, when they need help, the staff provide this in a way that suits the individual. Any change in a resident’s condition is quickly identified so that additional support can be provided to keep them safe and well. Written records of this work are very well kept. EVIDENCE: Every resident has a written plan of care. This tells the staff how they should work with the resident to be sure their care needs and wishes are met. The records at Evendine are very well written and are constantly updated. They are prepared on a computer so that they can easily be altered when there is any change in the resident’s situation. A relative was very happy with the Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 11 result of this work –‘I find the staff excellent and very responsive to the needs of the residents’. A resident spoke about being taken to see her G.P. the day before the inspection visit. The Providers had taken her and she had been prescribed some cream to treat her arthritic pain. G.P.’s, social work staff and district nurses sent in positive comments about the residents’ care – ‘residents are encouraged to be self-caring. However, some do border on needing extra care and attention, which they receive’. Medication is carefully managed at the home so that it is handled safely. Residents are able to manage their own medication if they wish and are considered safe to do so. One resident said she preferred staff to look after her tablets but she does like to know what she is taking. She had recently asked to see her medication to remind herself and the staff were happy to do this. She also had been given written information about her medication. Records seen at the home showed how staff were keeping an eye on a resident who prefers to continue administering his wife’s medication (she is also a resident). The couples’ key worker discusses the arrangements periodically with the resident. A sample of medication administration records was properly completed although there are one or two recommendations for strengthening practice. These are detailed at the end of this report. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 12 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. Residents are able to continue living in the way they prefer, and their relatives are actively encouraged to stay involved. Meals are planned and provided in a way that takes very good account of individual dietary needs and preferences. EVIDENCE: Residents have the opportunity to participate in regular social events inside and outside of the home e.g. local garden centre visits, pub visits, live musical entertainments, and religious worship. Some residents prefer to take things more quietly e.g. a resident was observed chatting to the Provider about the books she had just read. She was looking forward to the mobile library coming later that day so she could change them. Another resident felt that the weather was too cold to go out just yet, but she was enjoying the company of other residents and the staff and she would go out with her family when the warmer weather arrived. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 13 The catering staff know what each resident likes to eat, and if they are on any special diet. The staff try hard to satisfy each resident e.g. the cook used to buy a particular type of bread (in her own time) to please a resident. The records of food provided showed a considerable number of alternative choices being served. The cook completes feedback forms so that the Providers know what the residents think of the menu and can alter future menus if need be. She demonstrated a thorough awareness of the type of foods she needed to prepare for residents on special diets e.g. low fat, and a resident who was receiving this special diet was satisfied with her meals. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Residents know how to raise complaints and concerns, and when they do, these are carefully looked into. Staff understand how to protect residents from abuse and relatives feel confident that the staff will keep the residents safe while supporting them to continue living in the way they prefer. EVIDENCE: A complaints procedure is included in the residents’ information pack and is also displayed at the home. This makes it clear how to raise concerns about the service. Residents’ survey responses confirm that they understand how to raise any concerns. The Commission hasn’t received any complaints about the service, but the home keeps a record of any minor concerns raised and the action they have taken to respond to these. This record was inspected and indicated an open, balanced approach. The care records show how residents are encouraged to control their own lives but are also protected through regular monitoring of any potential risks. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 15 The staff receive training and guidance so that they can recognise any signs of abuse and know how to report them e.g. a staff member spoke about a relevant training course and had also signed to confirm she had read relevant guidance literature. Residents feel safe and a relative explained ‘our worries about moving my mother-in-law into a Home were completely unfounded as I am extremely happy with all the care she receives’. An independent advocate visits the home so that any resident who needs outside help in representing themselves can get this type of support. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 16 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a very attractive home that is maintained to ensure their safety and comfort. EVIDENCE: The residents’ accommodation is very well presented to a high standard. All areas were clean, warm and bright at the time of the inspection visit. The residents are very satisfied with their bedrooms. One resident commented that she was waiting for a larger bedroom but was not sure if she wanted to lose the lovely view from her current bedroom. Another resident had only been living at the home for a short while. She already had her own armchair at the home and was sorting out other personal pieces to make her Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 17 feel ‘at home’. It was noted that bedroom call bells had been put beside residents so they could easily summon staff help to their room. There is good attention to maintaining a safe and clean environment. The Provider arranges for all essential services and equipment to be regularly serviced and has an ongoing programme of work to make sure the standards remain high. A new bathroom had been introduced since the last inspection. This is large so that staff have plenty of room to help residents bathe. Two bedrooms have had en-suite facilities added and some others have been refurbished. Safety and hygiene is well managed. Staff have the written guidance and equipment they need to help them with infection control e.g. relevant policies and procedures, colour coded laundry bags, liquid soaps and paper hand towels. A new stainless steel sink and worktop had been fitted in the scullery area. Fire safety equipment was being properly used e.g. internal fire doors were only held open by the appropriate dorgard fittings. The Provider was monitoring any potential risks around the building e.g. a resident was supplied with her own cleaning sprays (she enjoys helping to keep her bedroom clean) only after considering whether this would be safe for the resident or others living at the home. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. There are enough staff to meet the residents’ needs although one or two people think there should sometimes be more. New staff are carefully vetted before being employed and all staff receive the training they need to work safely in their role. EVIDENCE: Most residents, relatives and visiting professionals feel there are enough staff to meet the residents’ needs. One resident felt that junior staff were often too busy to stop and talk although another stated ‘if I ring the buzzer it is always answered immediately’. A professional visitor also commented on ‘occasional staff shortages’. Staff were observed chatting to residents as they went about their work during the inspection visit and there was no sense of rushing through their tasks. There was a satisfactory level of staff at work during the unannounced inspection visit. A deputy manager was in charge until the Providers arrived later. She was experienced and qualified and described a thorough introduction to Evendine before being asked to undertake this responsibility. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 19 Separate catering and cleaning staff were on duty to support the care staff. When new staff are recruited they are carefully vetted to be sure they will be suitable to work with vulnerable adults. A sample of records seen at the home confirmed this, and the recently recruited deputy also described a satisfactory selection procedure. Almost half the care staff have an appropriate qualification (National Vocational Qualification) and training records indicate that all staff receive the health and safety instruction they need to work safely e.g. 19 staff have a first aid certificate. The cook spoke about a health and safety course she was currently doing, and she had received refresher food hygiene training within the last year. Training for care staff also includes care practices e.g. dementia care, medication management. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is excellent. 31, 32, 33, 35,36, 37 and 38. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents and their views are taken into account when future plans are developed. The management is very well organised to be sure that residents’ interests are protected at all times. EVIDENCE: There is considerable confidence in the way Evendine is managed – ‘run in a highly professional and caring manner’, ‘it is a place I would recommend’. Both Providers and the Care Manager have a recognised qualification and all have considerable relevant experience. Each manager has a clear job Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 21 description so that all aspects of the service receive thorough attention. The Providers work regularly in the home and this gives the Care Manager time to work out in the home supervising the care given by junior staff. A resident commented that ‘managers and seniors give me lots of attention’. Residents, relatives and involved professionals are regularly consulted about their views of the service and the Providers have good systems of monitoring the business so that they can plan how things can be further improved e.g. auditing minor concerns, accidents etc. Reports of these exercises are put in a file and made available at the home to residents and relatives. Computerised records support the administrative functions and a sample of inspected examples confirmed that the records were being kept up to date. Arrangements for insuring and safeguarding residents money and valuables were satisfactory at last inspection. There is a programme of staff individual supervision and appraisal. A staff member confirmed that she has six supervision sessions each year. One of the Providers takes the lead with health and safety arrangements. He attends relevant training courses to be sure he is aware of any changing legislation e.g. fire safety management. Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 x 3 3 3 3 Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 23 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. 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 2 Refer to Standard OP9 OP9 Good Practice Recommendations Staff should be reminded of the procedure for initialling to confirm double checking handwritten entries on medication administration records. Auditing medication stock would be easier if the first dose administered from new stock was identified on the medication administration record – most specifically when the medication is prescribed more than once each day. When staff have to decide when to administer medication prescribed ‘as required’ there should be a care plan that guides them in making consistent decisions for the individual resident. 3 OP9 Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Evendine House DS0000024707.V331498.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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