Inspection on 31/08/05 for Evendine House

This inspection was carried out on 31st August 2005.

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 22/02/07

Evendine House 20/12/05

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 Worcs. WR13 6DT. Lead Inspector Wendy Barrett Unannounced 31 August 2005 10:00 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 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 E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 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 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 Ltd Ms A C Billcliffe Care Home 20 6 6 2 20 Category(ies) of Dementia over 65 years registration, with number Mental Disorder over 65 years of places Physical disability over 65 years Old Age Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 December 2004 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 E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 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 3.45pm. Feedback questionnaires had previously been sent to the home for staff to contribute their views on the service. Four replies were received. This was too few to be able to draw any general conclusions from this exercise. The Providers, Mr. And Mrs. Bate, are normally actively involved with the everyday life of the home. They were away on holiday at the time of the inspection. The Care Manager was at work in the home and assisted with the inspection. A Head of Care, two care assistants and a cleaner were interviewed. The cook was met and provided information about the catering arrangements at the home. Four residents were interviewed and others were met around the home during the course of the day. A sample of records was inspected and there was a tour of the premises. What the service does well: The accommodation is situated in a very attractive rural setting. It is well maintained with high quality furnishings, fittings and décor. There is thorough attention to the physical safety of the home’s residents. Mr. and Mrs. Bate, the Providers, are actively involved on an everyday basis so they are readily accessible to the residents. This keeps them in constant touch with any issues that need their attention. Because of this support, the Care Manager can spend time working out in the home with residents alongside the junior staff. She is available to the residents and she can closely monitor that the care is satisfactory. The residents directly benefit from the combined knowledge and skill of these three seniors and the way they organise their work. The residents and staff are given lots of opportunities to express their views and contribute suggestions. This works well. The residents feel comfortable about speaking openly to Mr and Mrs. Bate or any of the staff. There is good information literature at the home to help everyone understand how to make the best of the service. The routines are very flexible to suit each resident. They can make choices about the way they spend their days, what food they eat etc. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: It would be better if the laundry was larger and the walkway through the kitchen was removed. However, this would not be possible within the current building and there is no evidence that these shortfalls are affecting the service to the residents. If there is ever a proposal to extend the premises these areas should be given further thought. Following discussions during this inspection, the staff are already considering how they can amend the way they keep records of medication supplies. Medication is already handled safely but this additional piece of work will make it even easier for staff to know what drugs they have in stock on any particular day. There have been no complaints made about the service for a very long time. Sometimes residents in care homes have little problems that are sorted out by the staff quickly. It may be helpful to keep a record of these minor concerns. Then Mr and Mrs. Bate can see if similar problems are cropping up regularly. If this happens they may be able to make adjustments that will stop these minor issues continuing. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 7 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 E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1, 2 and 3. Prospective residents have all the information they need to decide whether the home will suit them. Staff at the home also gather enough information to decide whether they will be able to meet the needs of prospective residents. EVIDENCE: A Statement of Purpose and copy of the last inspection report were displayed at the home. An example of a contract of residence was available. The resident and the Provider had signed this. The care records include details of a comprehensive pre-admission assessment. Mrs. Bate undertakes this work. She compiles an initial care plan based on the information gathered. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 and 10. Each resident receives care that is suited to their individual needs and preferences. This is offered in a respectful manner. Staff handle medication safely. A little more attention to the written records will help staff if they need to check current supplies of stock. EVIDENCE: Individual plans of care were seen at the last inspection. They covered all areas of need and were based on risk assessment when this was necessary. Residents seen during the current inspection had been consulted about their care service. The Care Manager undertakes monthly evaluations to ensure that each plan is up to date. The last inspection report describes a robust approach to the management of medications. The system was sampled on this occasion. Medication was securely locked in a fixed cupboard with a reinforced door. Controlled drugs were being properly secured. The remaining number of tablets in one sampled bottle was accurately reflected in the controlled drugs register. The audit trail for monitoring stock supplies of other medications was less well evidenced. The Provider is currently looking at ways to improve this aspect of medication management. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 11 Residents were very satisfied with the attitude of the Providers and staff – ‘never hear a cross word between them’, ‘everyone so friendly’, ‘I can talk to them’, ‘went to a lot of trouble to bring in my own armchair’. Staff were observed speaking sensitively to residents and seeking permission before entering their private space. A resident mentioned the kindness of staff at the time of her husband’s death. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 and 15 There is a very flexible approach so that residents can continue to live in a style that suits them and that meets any special needs they may have. EVIDENCE: Some residents were involved in group activities during the morning e.g. exercises, bingo. One gentleman was spending the day resting on his bed. He preferred to do this and staff and his family respected this life choice. Other residents were occupied in their bedrooms or were chatting to other residents in the communal areas. Meals are served wherever the residents prefer. A staff member was observed taking round a supper menu and asking each resident what they would like to eat. The cook sees most residents every day. She mentioned a married couple who have their own tea menu. Residents are able to make requests e.g. curry, cheese scones. A vegetarian menu is provided for one resident. There is a written record of alternative meals provided. Fresh produce and home baked cakes were seen in the kitchen. An extra cake is baked at weekends because they are so popular with visitors! Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16 and 18 Residents know how to complain and are assured of a swift response. Minor concerns would be worth recording because if they happen regularly there may be something that can be done to improve things generally. The residents are protected from abuse by staff who are equipped to recognise and report any related concerns. EVIDENCE: All residents receive a copy of the home’s complaints procedure. A complaints register indicated that there had been no complaints made at the home since 2002. This may be an accurate reflection but it may indicate that minor concerns that are quickly resolved are not being recorded e.g. items of laundry temporarily mislaid. Keeping a record of these incidents would identify any minor but recurring issues that may warrant further attention. The home has implemented policies and procedures to address adult protection issues. A cleaner gave a confident and informed response to questions about abuse. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19 and 26. The residents live in a very well maintained, safe and attractive environment. EVIDENCE: The home is very well maintained. It is situated in easily accessible and attractive grounds. There is a high standard of décor, furnishings and fittings throughout. There has been recent investment in upgraded bathing facilities with attention to the needs of residents who experience mobility difficulties. Everywhere was clean and odour free on the day of the inspection. Dorgard devices were being used appropriately throughout the building. Fire safety specialists approve these devices. The laundry room is very small but the Care Manager felt it was adequate. It was clean and tidy and the walls had been redecorated in response to a requirement arising from the last inspection. The floor was due to be recovered with an impermeable surface very shortly after this inspection. This work had been subject to understandable delay because a new drier had been Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 15 installed. The new drier is fitted with a water discharge devise to avoid it catching fire. There is a walkway through the kitchen. This is not ideal in terms of infection control but it is probably unavoidable due to the layout of the building. The Environmental Health Officer has inspected the kitchen and is satisfied with the situation. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 30 There are enough staff to make sure the residents needs can be met. The staff are well trained to be sure that residents are always safe. EVIDENCE: Staff met at the home felt that there were enough staff to meet the residents’ needs. The duty rota reflected a satisfactory number of staff at work during the day. A few agency staff had been employed through the summer to maintain a level of two staff on waking night duty. A cleaner was able to get through her work, particularly since the employment of a second cleaner. There were many examples of training opportunities. These included reference to N.V.Q. awards, health and safety training, and professional practice training e.g. dementia care. A matrix records each staff member’s training programme. There is a mix of internal, external and video instruction. The home has 6 certified trainers to help deliver the various training. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 and 38 There is good leadership, guidance and direction to staff to ensure residents receive consistent quality care. This results in a safe environment where staff work in the best interests of each resident. EVIDENCE: The Care Manager works closely with both Providers who are actively involved with the everyday life of the home. Residents have easy access to these senior personnel and staff feel well supported. Mr. And Mrs. Bate have achieved a Registered Manager’s Award. Mrs. Bate is now working on an N.V.Q. level 4 in care. The Care Manager has achieved an N.V.Q. level 4 award in care, and she is now working towards a Registered Manager’s Award. There is a clear understanding of the responsibilities of each member of the management team. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 18 The comments of staff and residents reflects an open approach to management with effective communication between all – ‘the seniors and the communication book tell me what to do’, ‘we have forms to write down problems or ideas’, ‘I can talk to Mr and Mrs. Bate – everyone is so friendly here’. There were examples of thorough attention to health and safety. A cleaner conscientiously removed a vacuum cleaner from a resident’s bedroom before leaving her work to be interviewed. She recognised the risk of a trip or fall if she left her equipment unattended. Bath temperature records were being maintained; labels on fire extinguishers showed they had been serviced within the last year, Mr. Bate attended a Fire Safety Management course earlier this year. Staff are receiving statutory health and safety instruction. Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 4 4 x x x x 3 Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 20 No 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 Regulation None 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 9 Good Practice Recommendations Medication procedures should be amended to introduce a system for introducing a simple audit trail of medication stock. Ideas were already being considered by staff at the time of writing this report. It is recommended that there be further consideration of the current methods of auditing minor concerns as part of the overall complaints management. Upgrading of laundry facilities and removal of the walkway through the kitchen should be included in any future proposals for extending the building. 2. 3. 16 19 Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Hereford Area Office 178 Widemarsh Street Hereford HR4 9HN 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 Evendine House E52 E02 S24707 Evendine House V247482 310805 Stage 4.doc Version 1.40 Page 22 - 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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