Inspection on 01/06/05 for Evergreen

This inspection was carried out on 1st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Evergreen 22/06/06

Evergreen 07/12/05

Evergreen 16/02/05

Evergreen 04/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Evergreen 290 Passage Road Brentry Bristol BS10 7HZ Lead Inspector Sam Fox Unannounced 1 & 29 June 2005 09.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Evergreen Version 1.10 Page 3 SERVICE INFORMATION Name of service Evergreen Address 290 Passage Road Brentry Bristol BS10 7HZ 0117 9501791 0117 9501791 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) Treehome Ltd Mrs P. Waters PC Care Home 6 Category(ies) of LD Learning Disability (6) registration, with number of places Evergreen Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 6 persons Date of last inspection 16 February 2005 (Announced) Brief Description of the Service: Evergreen is owned by Craegmoor Healthcare. It is registered to provide accomodation and personal care for up to six people with a learning disability aged 18 - 64 years. A number of residents currently accomodated have complex needs which can result in challenging behaviour. The premises is situated in a quiet residential area. It is a small house that blends in well with the immediate surroundings. There are some shops and local amenities in the vicinity. The home also has a min-van which residents use frequently to go out. Evergreen Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the main purpose of which was to check on progress made to requirements made at the previous inspection. Opportunity was also taken to inspect the premises and check care plans. Evidence was gathered through discussion with the manager and staff, inspection of records and observation. An additional visit was made as part of this inspection to speak with a senior manager, appointed by Craegmoor Healthcare, to oversee the day-to-day running of the home. Information and progress made as a result of this meeting will be included in this report. None of the recommendations made at the last visit were discussed during this inspection and some of these will be carried forward. What the service does well: What has improved since the last inspection? The carpet in the hall stairs and landing has been replaced. Works have also begun to replace and improve the kitchen. In addition to this the front of the premises has been cleared and a new fence has been erected. This has resulted in an improved environment for residents. All care plans have been re-written – these now enable staff to provide residents with consistency and to receive support which is tailored to individual need. Staffing levels have also been increased. Evergreen Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Evergreen Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Evergreen Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 Advocates of prospective new residents have information in an updated Statement of Purpose for them to make a more informed choice about living at Evergreen. EVIDENCE: At the time of the first visit the manager had not met a previous requirement to update the home’s Statement of Purposes. This was received on the second visit. It details the aims and objectives of the organisation and some of the facilities and services provided. This meets with requirements of the legislation The manager explained a number of the residents currently accommodated have been diagnosed along the autistic spectrum. She said that Craegmoor have employed a specialist in this field to provide input in to Evergreen and other homes within the organisation. Once achieved this should be a positive development and enable the home to provide a more specialist service. The manager may need to further develop the Statement of Purpose if this were to be achieved. Evergreen Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9 Care plans have been improved and now enable staff to provide more consistent and individualised personal care. These need to be further developed to include social and emotional need so the home can more easily demonstrate it is meeting the needs of residents with more complex behaviours. EVIDENCE: The manager explained that care plans and risk assessments have been updated since the last inspection and that information on files had been reorganised to include relevant information only. Opportunity was taken to inspect two of these. They were found to contain life histories, risk assessments and individual care plans. Care plans written in relation to personal care needs were written to good detail. They included, for example, preferred morning \ evening routines, support with hand and foot care, support with nutrition and dressing. These were written sensitively and gave a good picture of individual preferences and tastes- this represents an improvement since the last inspection. Evergreen Version 1.10 Page 10 An area in need of development, however, is support needed in relation to residents’ learning disabilities and actions to be taken to help them manage their own behaviours. At present care plans do not indicate that the home is providing a specialist service in this respect. Input from a specialist employed by Craegmoore should be useful in this respect. It was noted that all care plans are reviewed monthly and that there are more formal annual reviews. This is a positive development. There has also been some improvement in risk assessments for individual activities. There were, however, some which were not specific enough. For example, one identified risk was travelling in the car but it was not clear what the actual risk was. These need to be further developed and will be a continuing focus of the forthcoming visit. One member of staff said they were pleased because a resident had recently begun swimming lessons whom they has previously thought would not be able to due to the risk involved. This is a good example of how the home are encouraging residents to have more active lifestyles which entail some element of risk. Evergreen Version 1.10 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 Residents are supported to go out and be part of the local community. EVIDENCE: The manager explained that she has been developing weekly activities and was trying to broaden residents’ horizons as well as making what they do during the week more meaningful. Other staff confirmed this and said they were pleased to see some residents enjoying new things, such as swimming, aromatherapy and relaxation. The manager explained there is a provisional weekly activity plan which will be reviewed when a number of residents take up a college course in September. Members of staff said they like to ensure that residents have a good community presence and that they support them to use local amenities. This was observed at the time of the visit. Residents also have full use of the home’s mini van. Evergreen Version 1.10 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 There are good systems in place to ensure that residents’ health care needs are met. Then medication system needs to be improved to ensure that it is safer. EVIDENCE: A number of residents require support with their personal care needs and care plans in relation to this have been reviewed and improved to include individual preferences (Refer to standard 6). The manager needs to include whether residents prefer the help of a male or a female. Members of staff displayed a good knowledge of individual needs in this respect. There was evidence to indicate that residents receive the appropriate support to see the relevant healthcare professionals, including dentists, opticians and their own GPs. Opportunity was taken to inspect the medication system. One requirement made about stock control at the last inspection had been met. It was noted, however, that there were some gaps in the recording of medication administered. Action needs to be taken to ensure greater accuracy. In addition to this the home still needs to update the medication policy to reflect the care setting and current legislation (as required at the last inspection). Evergreen Version 1.10 Page 13 All staff have recently received training to ensure their competence to give out medication. Evergreen Version 1.10 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Urgent action needs to be taken to ensure that staff have the training and skills to support residents’ with complex learning difficulties which may result in challenging behaviour. EVIDENCE: Craegmoor has an established formal complaints procedure. This was not looked at in detail at the time of this visit. It was noted, however, that each care plan included how residents preferred to be communicated with. This is important, as a number of residents are unable to directly verbally communicate their discontent. Since the first day of the inspection the home has developed a policy and guidance on the use of physical restraint. This is a positive development. The manager needs to ensure that all staff are aware of and agree to this. Some residents have complex learning difficulties which, under certain situations, may lead to challenging behaviour. As such there is the possibility that staff would need to use physical restraint. It was a requirement at the last inspection that all staff have received training in supporting individuals with challenging behaviour. This has yet to be achieved and must be organised as a matter of urgency. (Subsequently a training date has been obtained for the end of July – it will, however, remain a requirement until fully achieved). In addition to this the home must: • Develop some form of “reactive” strategy for each resident which details trigger points which may lead to challenging behaviour and actions taken to reduce the likelihood of this. Version 1.10 Page 15 Evergreen • Inform the CSCI, via Regulation 37 Notifications, of any incident which involves the use of physical interventions. This is an area in need of major improvement within the home if they are to demonstrate that they are protecting and supporting both vulnerable adults and the staff group. It was noted that not all staff have received protection of vulnerable adults (POVA) training – this is now considered to be essential training for all staff – especially so because of the complex and challenging behaviours of some of the residents accommodated in the home. Last year there was a protection of vulnerable adult issue involving one resident’s money which went missing. Craegmoor have dealt with this situation appropriately and this has resulted in a member of staff being dismissed and being placed on the protection of vulnerable adults list. The organisation has also replaced the missing money. This meets with a requirement made at the last inspection. Evergreen Version 1.10 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,27 Residents live in a comfortable environment. EVIDENCE: Evergreen is residential in style and blends in well with the local environment. It is close to shops and other local amenities. Since the last inspection a new wooden fence has been put up and the front garden has been cleared. The premises is subject to wear and tear and as such requires a robust maintenance programme. On the first day of the inspection none of the requirements in relation to this had been actioned. On the second visit, however, the following had been actioned: • • • The kitchen, which was previously in a poor state of repair, was being replaced The carpet on the hall stairs and landing had been replaced The carpet in room 5 had been replaced. Evergreen Version 1.10 Page 17 An outstanding requirement in relation to the upstairs bathroom is carried forward to replace the lino. It was explained that this room was going to be re designed with new bathing facilities. This would considerably improve this room which is not ideally suited to its purpose and is not homely in appearance. None of the bedrooms were viewed during the inspection and will be a focus of the next visit. All areas of the house were seen to be cleaned to an adequate standard. Evergreen Version 1.10 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 Residents are supported by an enthusiastic staff team and there are now more staff on duty to enable residents to go out and lead more active lifestyles. EVIDENCE: Rotas evidenced that staffing levels have improved since the last visit. There are now four support workers on duty all day until 4.00pm – this then reduces to three. Staffing levels should not go below these levels. During the time of this visit there were six permanent support workers on the rosta. One member of staff said that whilst they felt they all worked well as a team this did not give much leeway if people were sick or on holiday. The manager explained that she is currently recruiting for more staff which should ease the situation. At the moment the home appears to be relying on permanent staff doing overtime on a regular basis. Opportunity was taken to view the personal file of the newest member of staff. This included a completed application form, two references and a CRB check. This person was employed from oversees and the manager was advised to obtain the organisation’s recruitment from oversee policy to ensure she had followed the appropriate procedure (for example in the obtaining of references). Evergreen Version 1.10 Page 19 It was also noted that the newest employee had not completed their induction within six weeks and there were gaps in their training. This is not accepted practice and a requirement is repeated from the last inspection that the home improves standards in this respect. The manager provided evidence to indicate that all staff have received a CRB check and the newest staff have received a “pova” check. This meets with a requirement made at the last inspection. The home have recently purchased a long distance learning package about autism. Whilst this is a positive development if the home were to reach its full potential then this should be used in tandem with more formal, direct input from a specialist. This will be a focus of the next visit. Members of staff spoken with displayed a commitment and enthusiasm to their roles. It was apparent that there have been a number of changes in the home within the last six months and that they have worked well as a team to get through these difficulties. Evergreen Version 1.10 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 Management systems need to be improved so that residents can benefit from a more organised and well run home. EVIDENCE: The manager has recently been registered (in the last six months) and has almost completed her NVQ Level 4. After this she needs to complete her Registered Managers award. During the first day of the inspection ten requirements made at the last inspection had not been met within the agreed timescales. Discussion took place about the legal responsibility to ensure that these are achieved in a timely fashion. The manager must ensure she demonstrates her competence more effectively in this respect. It should be noted, however, that this has been a time of change for Evergreen with a number of staff leaving and the Deputy post has been vacant for some months. The home is currently recruiting for two team leaders (replacing the deputy post) who will support the manager to fulfil her duties and to supervise staff. This should lead to improvements. Evergreen Version 1.10 Page 21 All staff spoken with said they felt the manager was fair and listened to them. There were no workplace risk assessments – these need to be developed for the home to demonstrate that the home is meeting with health and safety legislation. This repeats a requirement made at the last visit. All staff have training records – an examination of these indicated that not all had received their statutory training of first aid, manual handling or food hygiene. A requirement is made that the manager carry out a full audit of statutory training needs and arrange them accordingly. There were records of fridge and freezer temperatures. There was an up to date insurance certificate and gas safety certificate. There were records of weekly water temperature checks to ensure temperatures do not go above 43 degrees. The fire logbook indicated the appropriate tests and checks are being made of the fire system. Evergreen Version 1.10 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x x Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x x Standard No 11 12 13 14 15 16 17 x 3 3 x x x x Standard No 31 32 33 34 35 36 Score x x 2 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x Evergreen Version 1.10 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 13(2) Requirement Timescale for action 30\08\05 2. 3. 4. 5. 6. 20 23 23 23 23 7. 8. 9. 10. 11. 27 35 37 42 42 Update medication policy and ensure it is relevant to actual work practice within the home (REPEAT REQUIREMENT) 13(2) Ensure accurate rceroding of all medication administered (REPEAT REQUIREMENT) 18(1)( c ) Ensure all staff are aware of,and adhere to, policy on restraint 13(6) Ensure all staff receive protection of vulnerable adult training 12(1)(a) Develop individual strategies in relation to potentially challenging behaviour 18 (1)( c ) Ensure all staff have training in supporting individuals with challenging behaviour (REPEAT REQUIREMENT) 23 (2)(b) Replace lino in upstairs bathroom (REPEAT REQUIREMENT) (18)(1)( Ensure all new staff complete c) induction within set time limits (REPEAT REQUIREMENT) 18(1)( c) Manager to complete RMA 13(4) 18(1)( c ) Develop workplace risk assessments (REPEAT REQUIREMENT) Carry out audit of statutory training and arrange dates for Version 1.10 27\05\05 27\05\05 30\09\05 30\08\05 30\07\05 30\07\05 27\05\05 30\12\05 30\07\05 30\08\05 Evergreen Page 24 training accordingly 12. 18 12(1)(a) Include gender preferences on care plans 30\7\05 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. 4. Refer to Standard 6 9 34 27 Good Practice Recommendations Continue to develop care plans to include specialist support given Further develop individual risk assessments Become familiar with organisational policy on recruiting from oversees. Refurbush upstairs bathroom Evergreen Version 1.10 Page 25 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Evergreen Version 1.10 Page 26 - 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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