Inspection on 15/06/05 for Evergreen

This inspection was carried out on 15th June 2005.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 24/05/07

Evergreen 25/05/06

Evergreen 30/12/05

Evergreen 18/11/04

Evergreen 05/05/04

Evergreen 06/01/04

Evergreen 12/03/03

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

CARE HOME ADULTS 18-65 Evergreen 55 Barrow Road London SW16 5PE Lead Inspector Lynne Field Unannounced 15th June 2005 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 G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Evergreen Address 55 Barrow Road, London, SW16 5PE 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) 0208 677 4273 Janes House LTD Mr Atmah Victor Barsati PC Care home only 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2004 Brief Description of the Service: Evergreen residential care home provides accommodation and support for up to three younger adults who have support needs due to enduring mental health difficulties. The service is located in a former private house, which is sited over three floors in a quiet residential street and is indistinguishable from other houses in the street. The home is situated close to shops and amenities and has good access to public transport. During the inspection it was evident that the home has been well maintained and offers a homely physical environment for service users. The ground floor has a staff office, kitchen/diner, and a large communal lounge area. To the rear of the home there is a large garden. The first floor has the service user bedrooms, a toilet, and a bathroom with shower facility and toilet. The upper floor has sleeping accommodation for staff. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and consisted of one visit conducted on 15th June 2005, during the afternoon. The findings were informed by general observations, discussion with the three residents, discussion with the manager, one member of staff and inspection of records A tour of the premises took place. There was one member of staff on duty. All three of the service users were spoken to during the course of the inspection. What the service does well: What has improved since the last inspection? Staff and management have become better at promoting and supporting service user’s independence, such as encouraging service users to access the community more and to become more active. One service user will now make his own appointments and has become more independent. Another service user’s confidence and mobility has been improved since the last inspection. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 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. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 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 G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 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) 1,2,3&5 The statement of purpose and service users’ guide used by the home contains the required information service users would need to help them make a decision about coming to live at the home. EVIDENCE: There have been no vacancies for the past four years and therefore no new admissions in that time. However, there is documentary information on file that indicates that the home obtains a full assessment of service users prior to admission, and obtains current and previous related documentation. Since the previous inspections the Manager of the home has continued to develop the contract given to service users. Service user records contain a basic contract outlining terms and conditions and it includes the personal support, facilities and services provided, a copy of the Service User Plan, and arrangements for reviewing needs and progress as well as an updated Service User Plan. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 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) 6,7,8,9,10 Care plans are thorough and reflect service user’s needs and goals. Service user participation in the running of the home had been facilitated where feasible and risk had been assessed on an individual basis to ensure service user’s safety. EVIDENCE: A new care planning system has recently been introduced and the manager has completed new care plans for the three service users. These plans are comprehensive, based on information received from relevant assessments and specialists and information known about service users from their residence at the home. The service users are involved in reviewing the care plans with the key worker. Two of the three care plans have been signed by the service user (the other service user is unable to sign due to a disability). The Inspector was shown the daily record sheets, which had recorded instances where the service users had exercised choice regarding activities of daily living. This is recorded in the service user plan and signed by the service user. The manager informed the Inspector that service users were encouraged to participate in the running of the home. Service users described to the Inspector how they helped with the laundry and helped wash up. The Inspector Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 10 was told by the activities coordinator one service user enjoyed cooking and helped prepare and cook the evening meals at times. The home has full and comprehensive risk assessments in place for all service users. The Inspector noted they were well written and thorough, referring to each possible area of risk for individual service users, denoting the degree of each risk, how it should be handled and with names and contact numbers of relevant professionals where appropriate. The home has a policy on confidentiality. Confidential records are kept securely within the office of the home. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 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) 11 - 17 Service users are supported and encouraged to access community facilities and take part in appropriate leisure activities, both inside and outside the home. They take part in enjoyable and fulfilling activities and mix with the general community. Service users are supported to have appropriate personal and family relationships, and are offered a healthy diet in a relaxed and cheerful atmosphere. This contributes to the service users emotional and physical health care needs. EVIDENCE: Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 12 There is an activities co-ordinator to support service users to attend a variety of activities ranging from in house activities to using the local facilities such as the Library or leisure facilities. One service user said they attend a day centre once per week and visit the local shops independently. Two of the service users access the local community independently and as they choose, using local shops, local amenities and attending local events. The home continues to get a copy of the weekly local paper so that service users can find out about local shows and events that they might be interested in. At a previous inspection one service user told the Inspector they chose not to socialize and preferred to stay at home. The Inspector was told this was something the staff at the home respected but always gave the service user the opportunity to go out when an outing was planned. There was evidence in the service user’s files seen by the inspector and from discussions with service users that they are supported to maintain links with family and friends according to their individual choices and circumstances. One service user has regular contact with family and friends, and another has less frequent but regular telephone contact with family. The third service user does not have known family but has social contact at the day centre attended weekly. The activities coordinator and staff at the home will initiate and maintain contact with families and friends on behalf of the service users when it is appropriate. Service users said they enjoyed the food that the home provided and menu records seen indicated that service users have a nutritious and varied diet, with complete flexibility according to their individual choice and tastes. The home enables service users to take as much responsibility as possible for the planning, and preparation of meals, and there is some flexibility around mealtimes. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 13 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 Staff provide sensitive and flexible personal support and service user’s physical and emotional health needs are met. Administration of medication was generally in good order with the exception of the way the medication is checked and recorded when it comes into the home. The registered person must make sure all medication received is recorded accurately at the time of receipt and a running total is kept on the medication sheet. EVIDENCE: Service users require prompting to carry out personal care and at times require support. Speaking with staff and observation of practices demonstrated that support and prompting is carried out sensitively and in a way that ensures service user’s privacy and dignity. Service users were dressed and groomed according to their interests and personalities and photos displayed in their rooms indicated that staff ensure they are appropriately and stylishly dressed when they attend outside activities, day trips and events. Documentation and verbal evidence from staff also demonstrated that service users are supported to access the full range of health care professionals and facilities and that appropriate consultation and support had been sought from specialist teams. Each service user has a care coordinator and the CPN calls every two weeks. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 14 Storage and administration of medication was checked and found to be in good order with the exception of the way the medication is checked and recorded when it comes into the home and then recorded on the medication charts. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 15 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) 22-23 Service users feel safe at the home and able to speak to staff, so that they could feel confident that their views would be taken seriously. The manager and staff act appropriately to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: Service users said that they felt safe at the home and able to complain. From direct observation, there was evidence that service users interacted easily with staff. There was a variety of ways to encourage comments from service users, including monthly visits from the provider. There is an adult protection procedure, including whistle blowing. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 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) 24-30 The home is homely, comfortable and safe, with appropriate personal and communal space, and a clean and hygienic environment. Service users live in a home that they find comfortable and where they can personalise their space. A lot of work had been done to render the premises more suitable to service user’s changing needs. Attempts had been made to embellish the environment to create a homely feel. EVIDENCE: The service users who showed the inspector their rooms showed evident satisfaction with their rooms and with the premises. The service users said that the facilities met their needs. All rooms had been personalised and decorated according to their occupants’ choice. The premises were generally bright, clean and spacious. The home had a range of communal space available for the service users. These included a large garden, sitting room and kitchen dining room There was a policy in place to control the spread of infection. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 17 The laundry was located separately from the kitchen and washing and drying machines had the necessary wash cycles to ensure that hygiene could be maintained. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 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) 32,33,35 There is an effective and well supported staff team who support the service users individual needs. EVIDENCE: In speaking to the support worker and the Manager, and observing the support worker interacting with service users, staff demonstrated accessibility, approachability, a good knowledge of the disabilities and specific needs and behaviours of service users, and good professional relationships with external health and social care workers. Induction training includes all basic training needs such as health & safety, food hygiene, manual handling, fire safety. Staff stated that they had received mental health training and are supported to take NVQ Level 2 training, and six staff have completed NVQ level 2. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 19 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) 37-43 The Manager is sufficiently knowledgeable and competent to run the home in a way that ensures the care and safety of service users and an effective staff team. Records are generally in good order. No problems were found with the overall management of the service. EVIDENCE: A range of records were seen and were generally in good order, ensuring that service users’ rights and best interests are safeguarded. All members of staff are provided with training as part of their induction within the first six months. Staff have had training in aspects of care, such as abuse and protection training, principles of risk management, managing abusive and aggressive behaviour and the safe handling of medication. There are a number of systems by which success can be monitored, such as the monthly audit check, which the registered manager does to monitor the environment. It continues to use a Department of Health questionnaire called Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 20 CUES (carers and users expectations of services) to evaluate and monitor service users satisfaction and care planning. There is a monthly health and safety checklist. The home had recently installed a new fire alarm system and fire extinguishers. The inspector saw relevant health and safety records that were in order. Service users have meetings every two months where they can feed back any concerns they may have. Two service users files were seen and these appeared to have the relevant documentation required. Records seen include, records of service user finance, including one where the service user had signed an agreement about how to control his finances, accidents and incidents, medication administration, complaints and record of visitors to the home. There was more evidence in the records about how service users are involved in reaching goals on a daily/weekly basis. Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 21 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. 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 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 N/A 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Evergreen Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 22 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 YA20 Regulation 17(1)(a) Requirement The registered person must make sure all medication received is recorded accurately at the time of receipt and a running total is kept on the medication sheet. Timescale for action 12 October 2005 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 Good Practice Recommendations Evergreen G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 46 Loman Street Southwark SE1 0EH 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 G52-GO2 22799 Evergreen 231642 150605 Stage 4.doc Version 1.30 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. 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