Inspection on 10/05/06 for Evergreen

This inspection was carried out on 10th May 2006.

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

Evergreen 27/06/07

Evergreen 09/12/05

Evergreen 23/06/05

Evergreen 14/12/04

Evergreen 05/08/04

Evergreen 05/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Evergreen 2 Brandreth Road Mannamead Plymouth Devon PL3 5HQ Lead Inspector Jane Gurnell Unannounced Inspection 10th May 2006 09:40 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 Evergreen DS0000003477.V294544.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. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Address 2 Brandreth Road Mannamead Plymouth Devon PL3 5HQ 01752 665042 NO FAX 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) Mrs Jacqueline Denise Tope Mr Roy Richard Tope Mrs Jacqueline Denise Tope Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 60 Date of last inspection 09.12.05 Brief Description of the Service: Evergreen is situated within walking distance of Mutley Plain shopping precinct in Plymouth. The establishment is formed from two terraced Victorian villas that have been internally combined. The home has a family atmosphere due to the efforts of the owners and the staff, and because the home can only accommodate sixteen residents at any one time this ensures a non-institutional atmosphere. The home has the category of OP (older person) and has neither of the specialist categories for the provision of dementia care or severe physical disability. The home specialises in creating a homely environment to meet the individual needs of each resident. Currently the fees charged are £325 a week. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 10th May 2006. Mrs Meertens was present during the inspection and she and her staff team assisted the inspector throughout the inspection. The focus of the inspection was to consult with the residents and review the care planning processes and related documentation. The inspector spoke to 13 residents, toured the building and examined care records and other documents relating to health and safety issues. Written surveys were provided for all residents and their families should they wish to comment anonymously. Nine surveys were received from residents and 3 from relatives: all commented favourably about the care home. A social worker visiting at the time of the inspection commented favourably about the services provided. What the service does well: What has improved since the last inspection? What they could do better: Mrs Meertens was able to demonstrate that the issues identified by the inspector had already been identified by her and Mr and Mrs Tope. These include increasing security by continuing to fit bedroom door locks, protecting residents from the risk burns by continuing to cover all radiators and upgrading the laundry room facilities to ensure that they are easily cleanable and reduce the risk of cross infection. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 6 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. Evergreen DS0000003477.V294544.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 Evergreen DS0000003477.V294544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Thorough and comprehensive systems for admission allow residents and their relatives to be confident that their needs can be met. EVIDENCE: Evergreen is a small home and as such vacancies for new residents become available infrequently. However the inspector had the opportunity to speak with a newly admitted resident who described her visit to the home before making a decision to move in. She said that she had been made very welcome and had been given information about the services provided. Pre-admission assessments are undertaken to ensure the care staff are aware of residents’ needs before moving in and can confirm that these needs can be met at Evergreen. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 9 Prior to the resident described above moving into the care home a physiotherapist assessment had been undertaken to enable the owners to provide the appropriate equipment necessary to assist this lady’s mobility, indicating that the providers take active steps to promote residents’ independence. A Statement of Purpose and Service User Guide were available for prospective residents and provided a clear description of the services offered; a further information pack is available for residents and their families and provides information about local services and life at Evergreen. Evergreen DS0000003477.V294544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents’ health, personal and social care needs are being met and residents are treated respectfully. Medication storage and administration practices are safe. EVIDENCE: Residents said they could not be treated better and described living in the home “lovely” and “excellent”, with one resident saying that “you couldn’t find a better home”. Residents said how very much they valued the family atmosphere of home with Mr and Mrs Tope and Mrs Meertens, their daughter, owning and managing the home. Further positive responses were received using the written surveys from residents and relatives who had the opportunity to comment about the care home anonymously. Those care plans examined detailed residents’ personal and health care needs and included risk assessments relating to activities of daily living, mobility and falls. There was evidence that the plans had been updated when residents’ needs changed. Mrs Meertens confirmed that all the residents’ care needs were Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 11 reviewed monthly when a summary of their well-being was recorded in their care notes. Mrs Meerten was advised to record this review to demonstrate their good practice. Detailed care notes were written for a resident who had been very poorly recently indicating that close attention was being paid to changes in residents’ health and further medical advise had been sought promptly. A local GP also completed a comment card favourably about the care home. Medication is stored safely and the records of administration were neat and accurate. There were no controlled drugs at the care home however additional secure storage was available should it be necessary. Care staff confirmed that they were currently undertaking a distance learning course with a local college regarding the safe handling and administration of medication to support their knowledge and safe practice. Evergreen DS0000003477.V294544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in the outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents are supported to maintain their independence and chosen lifestyle. Meals are plentiful, varied and nutritious. EVIDENCE: Residents described that they are encouraged to come and go freely from the home and to maintain contact with family and friends. Leisure and social activities organised by external facilitators are planned several times a month: a list is provided on the notice board and the residents said that these were much enjoyed. The care home maintains links with the local primary school, and at certain times during the year, for example at Christmas, invite the children to attend the home to celebrate with the residents. Care staff facilitate spontaneous activities with residents according to the weather and their wishes, such as visits to the local shops and other places of interest. Relatives and friends are welcome at the home at all reasonable times. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 13 The residents said that the meals were plentiful and very good and provide a well-balanced diet. Residents said that they had recently been consulted over the day-to-day management of the home and the services provided and this had included consultation about the menus and the choice of food residents would prefer. Evergreen DS0000003477.V294544.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The quality in this outcome group is good. This judgement has been made using the available evidence including a visit to the service. Complaints and suggestions from residents, relatives or other visitors to the home, are treated seriously. Residents are listened to and issues resolved promptly. EVIDENCE: Residents said that the owners and staff were very approachable and they were confident that any issues of concern would be listened to and dealt with. No complaints had been received since the last inspection. A copy of the complaints procedure is available to all residents and visitors and detailed in the home’s Statement of Purpose and Service User Guide. The information pack provides a statement of residents’ rights and information about advocacy services. Staff have received training in issues relating to abuse and the protection of vulnerable adults and described the actions they would take should an issue of abuse be suspected. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 15 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): 19, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents live in a pleasant, well-maintained home that is comfortable and warm and which provides sufficient facilities to meet their needs. EVIDENCE: All communal rooms and bedrooms were pleasantly decorated and furnished, reflecting the period of the building. Residents said that the home is always very clean. Residents are provided with a small safe to store valuables and the owners have started to fit bedroom door locks that provide both privacy and security: the owners should continue with this to ensure residents are confident that their property is secure. Radiators identified as posing a risk of burn injuries to residents have been covered and the owners are continuing to cover radiators Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 16 as each bedroom is decorated. Mrs Meertens confirmed that hot water control valves have been fitted to baths to protect residents from the risk of scalds. Mrs Meertens has produced a maintenance programme for the forthcoming year that provided details of the plans to refurbish and upgrade the environment. These plans include creating two additional single bedrooms with either en suite facilities or access to a private bathroom and upgrading the laundry room to ensure that it is easily cleanable, reducing the risk of cross infection as it is currently being is used as a store room for the freezers and other items not required in the home. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29, 30 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents are cared for by well-trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment processes protect vulnerable residents. EVIDENCE: At the time of the inspection there were 14 residents living at Evergreen. There were 3 care staff on duty and staff confirmed that this is usual. They confirmed that there are 2 care staff in the afternoons and evenings and 1 waking and one sleeping-in member of staff at night. In addition to this with the exception of Tuesdays and Wednesdays, when they are available on-call, Mr and Mrs Tope work everyday including the evenings and they also sleep–in. Mrs Meertens also works in the home full-time. Both care staff and residents felt that there were sufficient care staff available. Domestic staff are employed each weekday morning. Many of the care staff have worked at Evergreen for a considerable period of time and as such are very experienced. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 18 Care staff confirmed’ and records supported, that they have undertaken training in manual handling, first aid, fire safety and food hygiene. In addition to this the majority of care staff have completed NVQ training to either level 2 or 3. Those care staff files examined provided evidence that recruitment processes were safe and the required documentation had been obtained. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 19 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): 31, 32, 33, 35, 36, 37, 38 The quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents live in a well managed home. The owners and their staff team strive to provide a homely, stimulating and safe environment that respects and protects residents’ rights. EVIDENCE: Residents said they feel safe and secure in their home and that the home was very well managed. Mr and Mrs Tope are available each day, including weekends and meet with residents, relatives and staff on a daily basis. Their frequent attendance ensures consistency in care and ensures good relationships are maintained not only with the residents but also with relatives and other health care professionals, such as social workers and GPs. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 20 Staff confirmed that they meet with the owners regularly to ensure that residents’ needs continue to be met and any issues dealt with promptly. Records confirmed that staff receive supervision to review their work performance and training and development needs. Both Mrs Tope and Mrs Meertens have NVQ 4 in Care and are nearing completion of the Registered Manager’s Award indicating that they have successfully demonstrated their knowledge in the care and management issues of owning and running a care service. The owners provide safekeeping for money for 3 residents: individual records were maintained and receipts kept for all expenditure enabling this money to be easily audited. Mrs Meertens described her and her parent’s commitment to continually improving their services. A record of recent resident and relative consultation was available from March of this year and detailed views about the service and support provided by the home: comments were very favourable. Further indepth consultation was undertaken regarding menu variety and meal choices; the time of getting up and going to bed; involvement in hobbies and leisure activities and involving residents more in the affairs of the home. Surveys were also sent to care staff as part of the quality assurance process and a staff meeting was held to discuss relevant issues. Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations Evergreen DS0000003477.V294544.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 DS0000003477.V294544.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!