Inspection on 16/05/07 for Evergreen

This inspection was carried out on 16th May 2007.

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 13/03/09

Evergreen 17/04/08

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Evergreen 15 Collier Road Hastings East Sussex TN34 3JR Lead Inspector Melanie Freeman Key Unannounced Inspection 10:00 16th May 2007 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 DS0000068670.V336917.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 DS0000068670.V336917.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Address 15 Collier Road Hastings East Sussex TN34 3JR 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) Greenheart Enterprises Ltd Miss Natasha Nicole Edwards Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Evergreen is a registered independent care home providing nursing and personal care up to a total of 16 people over the age of 65 years. The home is situated approximately within I mile or walking distance of the seaside town centre and mainline rail station. The building has been upgraded to meet the National Minimum Standards and was registered at the end of 2006. It provides 16 single rooms with en suite toilets. Communal space is found on the ground floor and includes a lounge, dining room and a large conservatory. The home provides nursing care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees as from 01 April 2007 range between £575- £750 per person per week. Additional costs are charged for hairdressing, chiropody newspapers/ magazines and toiletries. The homes literature states that the homes ‘mission is to maintain, restore and promote to exceptional standards the health, safety and welfare of each individual in our care’. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Evergreen Nursing Home will be referred to as ‘residents’. This was a the homes first key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting social care professionals. The unannounced assessment visit was facilitated by the registered manager who was working in the home and is also the responsible individual and director of the company that owns the home. On the day of the home assessment the inspector was able to spend much of her time meeting with residents and their visitors and observing practice. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, care plans, duty rotas, medication records, and recruitment files. The care documentation pertaining to two residents were reviewed in depth along with a number of policies and procedures and records relating to health and safety. The inspector was able to eat a midday meal with the residents in the communal dining room. During the visit six visitors were spoken to and were able to provide their views on the home and services provided. Following the visit one relative was contacted by telephone along with three social care professionals. What the service does well: This was a positive inspection where it was found that the registered manager of the home is committed to providing a good standard of care. The atmosphere at the home was relaxed, with communication between staff, residents and visitors being positive open and friendly. The home provides prospective residents and their families, with a good level of information about what services are provided at the home. All residents, relatives, visitors and visiting professionals contacted as part of the inspection process confirmed a very high satisfaction with the home, care and staff. One relative said ‘the home has been marvellous they have done an amazing job with my mother. I am very impressed with the care’. One resident said that ‘she enjoyed living here’. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 6 Evergreen is a converted premise that has been updated recently and provides a home like environment that is pleasant and attractive. Observations made during the inspection confirmed that staff are caring and respectful in their interactions with residents, and that their needs were being attended to. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Evergreen DS0000068670.V336917.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 DS0000068670.V336917.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures ensure residents are suitably assessed prior to their admission by a competent person, who ensures that the home admits only those residents who’s needs can be met by the home. Intermediate care is not provided at Evergreen Nursing Home. EVIDENCE: The statement of purpose and service users guide was available in the office area and the registered manager confirmed that all residents are given a copy of these documents. A review of these documents identified that they needed to be updated now that the home is operational and need to include a copy of resident’s terms Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 9 and conditions of residency and a record of all room sizes. The manager confirmed that this would be progressed. The assessment of the admission process included the review of the last two admissions to the home. The admission process followed included a full assessment of need being completed and documented by the registered manager. This assessment is completed in consultation with other care professionals and relatives as appropriate and is incorporated into the homes documentation once the resident is admitted. In order to maintain clarity in the care documentation it was recommended to the manager that the assessments completed prior to admission are clearly titled and confirmed when, where, and by whom the assessment was completed. The manager confirmed that all prospective residents or their representatives are advised verbally that following the assessment the home is able to meet their needs. The manager confirmed that in the future she would confirm this in writing in accordance with the required documentation. Relatives spoken to were happy with the admission process confirming that they had the opportunity to visit the home and that in one case the home had been recommended. Care professionals contacted were impressed with the admission process one saying ‘the assessment process is professional and appropriate’. The manager confirmed that intermediate care is not provided at Evergreen. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although care documentation provides a framework for the provision of care it needs to be developed along with robust systems for risk assessment to ensure individual person centred care is delivered. The homes practice ensure resident’s medicines are stored and administered safely and residents are treated with respect and have their privacy and dignity maintained. EVIDENCE: Two individual plans of care were reviewed in depth as part of the inspection process and confirmed that these provided a basic framework for staff to follow. However they were found to be generalised and did not reflect accurately the care provided or give clear individual guidelines for staff to follow in order to promote a person centred approach to care. For example residents who had ulcers did not have a corresponding plan of care, one plan indicated that resident needed ‘to be positioned to optimise comfort’ but did Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 11 not record how, those residents identified at being at risk of pressure sore development did not have clear plans of care to reduce the risk and one resident’s plan of care recorded that her Blood Pressure needed to be recorded but did not say where or when. It was also noted that resident’s social emotional and psychological needs were not assessed or addressed within the care records. There was evidence to confirm that the care plans are being reviewed and a daily record is written staff spoken to had a good understanding of individual residents needs. There was however no evidence that the plans of care are written in consultation with residents or their representatives. This shortfall was identified to the registered manager. The registered manager has a good understanding of the community health care services and residents are supported in accessing these as necessary. It was however noted that the use of risk assessment was very limited; ‘bed rails’ were in use without appropriate risk assessment. Residents do not have a nutritional screening and risk assessments for those residents at risk of falling are not completed. The registered manager is aware of the need for individual and environmental risk assessment and confirmed that she is developing suitable risk assessment documentation. All feedback received from residents, relatives and visitors confirmed a satisfaction with the care provided and comments included ‘I am pleased with the care and attention that my husband gets at the home’ ‘my father in law is very well looked after and I have been impressed with the service’ ‘I am impressed with the care’. Feedback from the care professionals spoken to were also positive about the home recognising that it was a new home but being optimistic that the good start of the home would continue and be maintained. A selection of resident’s medicine records were reviewed and on the whole the records were full and clear. The manager advised that she was working with a local community pharmacist to implement a monitored dosage system and to ensure suitable storage and procedures are adopted in the home to ensure safe medicine administration. During the assessment visit to the home it was noted that staff had a very good rapport with residents spending time with them and their visitors having conversations and interacting in a positive and respectful way. Staff knew all the residents well and addressed them by their preferred name, which was clearly recorded within the care documentation. Resident’s rooms were found to be attractive and personalised many having their own furniture. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with friends and relatives are encouraged and choices made are respected. Resident’s opportunities for stimulation through leisure and recreational activities are not fully developed in the home to meet individual needs. Residents receive a wholesome and appealing diet. EVIDENCE: The assessment of resident’s social and psychological needs is not well developed and during discussion with the registered manager she confirmed that she was hoping to record life histories on all the resident with the help of residents and relatives, in order to find out more about individual needs and preferences. During the assessment visit staff were seen to be interacting well with residents and residents talked about the games that are played in the home which some said that they enjoyed. One resident talked about a trip she had Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 13 out with one of the carers that included some fish and chips. The manager said that individual time is available for some outings but acknowledged that further development of individualised social activity is needed. All visitors spoken to said that they are always warmly welcomed when they arrive at the home and that they can visit when they want and that any messages left are passed on to the residents promptly. One relative also confirmed that the home had helped in arranging regular visits to a day centre for therapy. During the inspection it was noted that choices were given to residents around what sort of drinks they wanted, where they wanted to be, and what they wanted to do. However discussion with two residents indicated that they did not always go to bed at a time of their own choice. Discussion around ensuring that the home does not get regimented or task orientated took place with the manager and it was recommended that individual choices were explored and documented within the care documentation. The meal eaten by the inspector with the residents was found to be attractive and appetising to eat. The main meal was shepherds pie with fresh vegetables and although there was no other choice residents and staff confirmed alternatives are readily available if the main meal is not suitable. The evening meals are more flexible with the cook responding to individual choices made. The dining room was found to be rather cramped with eight people eating in it and this could be improved if residents had more suitable chairs to sit in with arm rests instead of sitting in wheelchairs. One resident needed assistance with feeding and this was completed in a sensitive manner. Residents were seen to enjoy both their lunch and evening meal and comments received included ‘I had exactly what I wanted for tea it was lovely’. ‘The food is good and home cooked’. The manager discussed the use of menus and how she was going to record what resident actually had to eat. It was also good to see that when residents were sitting in the lounge area they had individual jugs of fresh water next to them. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that any complaint would be listened to and responded to appropriately. Practice in the home ensures that adult protection issues are responded to when identified. EVIDENCE: Although a complaints procedure is set out within the statement of purpose with a complaint form attached, the procedure needs to be further extended to identify who would investigate any complaint that was unresolved by the manager or is about the manager (who is also the responsible individual and director of the company that owns the home.) All residents, relatives and health care professionals spoken to about concerns and complaints said that they would be comfortable and confident in raising matters with the registered manager. In addition one relative said that when her relative spoke to the manager about a concern it was resolved quickly. Although the home has the local guidelines on safeguarding vulnerable adults it does not have a home policy or procedure and this is needs to be provided and supported with appropriate training on this subject for all staff working in the home. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 15 It was clear from discussions with the manager that she had a good understanding of what action to follow following a suspicion or allegation of abuse and had discussed an issue unrelated to the home appropriately with Social Services. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents live in an attractive home like environment that is well maintained and clean although further attention needs to be given to the safety of residents. EVIDENCE: Evergreen is a converted premise that has retained a home like environment and has been upgraded to meet the National Minimum Standards. Accommodation is provided on three floors with disabled access to the first floor via a passenger shaft lift. A tour of the home confirmed that a good standard of decoration is maintained throughout along with a good standard of cleanliness. All rooms are single and have en suite facilities, all are attractive and those that are occupied were found to personalised. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 17 The inspector was concerned to note that the two en suite baths were being supplied with water over 70 degrees C, along with one hand basin in a communal bathroom. Once this had been identified to the registered manager she arranged for the home’s handyman to come to the home to ensure these three areas were controlled to a safe temperature. When the handyman arrived he was able to identify that the en suite baths did not have individual control valves fitted to them. By the end of the assessment visit the hot water had been controlled to the hand basin and a valve was being fitted to the en suite bathroom in use the other room with this facility was unoccupied and was locked to ensure resident safety. Contact with the manager following the inspection confirmed that all areas supplying hot water to areas accessible to residents have been checked and all areas now provide hot water at a safe temperature. During the tour of the home it was noted that some residents with urinary catheters had their night drainage bags in their en suites rooms rather than being disposed of. The manager confirmed that this was not the practice that should be followed and said that this would be addressed to ensure a new bag is used each night. It was also noted that some residents may need an adjustable bed and this needs to be assessed, risk assessed and responded to by the registered manager. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is sufficient staff that are suitably trained on duty to ensure that residents receive the level of care they need. The homes recruitment procedures followed were found on the whole to be good although improvement is needed with regard to confirming identification. Systems need to be progressed to ensure that the staff team receive induction and a rolling programme of training. EVIDENCE: At the time of this assessment visit 10 residents were living at Evergreen, the residents have a mixed dependency some being mobile and not needing a high provision of care. Staffing arrangements provide three staff during the day and this includes the manager. Two waking staff work at night and a trained nurse is on duty 24 hours a day. Currently the care staff are completing the domestic duties in the home and the occupancy and dependency of residents accommodate this arrangement at the moment, although this needs to be kept under review to ensure suitable and appropriate staffing at all times. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 19 Staff working in the home were positive about working in the home and one said ‘she enjoyed working in the home as there was time to sit and talk to residents’. All feedback received from residents and visitors confirmed that the staff and the home manager are well thought of ‘I’ve been impressed with the service and the staff and how they treat people’ ‘Staff are all very kind’. Interaction between staff and residents was seen to be positive and respectful. The recruitment files pertaining to the three staff were reviewed as part of the inspection process and identified that the recruitment practice was satisfactory although confirmation of staff’s identification and photographs were not being retained. It was also noted that there was no evidence that staff received • Terms and conditions of employment • Induction training • A copy of The General Social Care Councils code of conduct Discussion with the manager confirmed that most care staff working in the home have completed a National Vocational Qualification in care however it was identified that staff training needs to be established and recorded for all staff working in the home. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is managed in an open and friendly manner with suitable quality monitoring systems. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are not well protected in all areas. EVIDENCE: Evergreen has been operational and admitting residents from January 2007. Although the registered manager has not worked within care homes before she has worked in a local hospital in the specialist area of caring and nursing older people. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 21 She has completed a National Vocational Qualification in management and now only needs to be assessed with in the work environment in order to attain her certificate. During the inspection there was no doubt that the registered manager had a good working relationship with everyone in the home and was managing the provision of care in the home well. All staff, residents and relatives spoke highly of her saying ‘the manager has been supportive and helped with complicated forms’ ‘she is a good manager’. Professionals spoken to were also complimentary saying ‘I knew the manager when she worked in the hospital and she was a good staff nurse and I am not surprised that the care in the home is very good’ ‘Feedback from relatives has all been very positive’. The registered manager is also the responsible person and the director of the company’ which owns the home. In order for her and the homes performance to be reviewed an independent registered nurse carries out monthly assessments to the home. There are systems in place to assess the quality of care and these are to be used once the home has been operational for 6 months. The manager confirmed that she does not have any involvement with resident’s monies and all residents have an identified person who deals with their finances any extras are invoiced on a monthly basis. During the inspection visit it was noted that environmental risk assessments are not completed and individual risk assessments need to be developed. The inspector was very concerned that risks around the provision of hot water in the home had not been identified and assessed putting residents at risk. It was also noted that door wedges were around the home and are used on some rooms for residents who want their doors open. The manager said that this matter had been discussed with the fire officers and agreed to include this matter in the fire risk assessment. She also confirmed that automatic closers that respond to the fire alarm are to be fitted in the future. When checking the homes certificates it was noted that certificates relating to the safety of lifting equipment including the passenger lift were not readily available. This was discussed with the registered manager who agreed to follow up on this matter. Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 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 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No previous 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 OP7 Regulation 15 1 2 (b)(d)18( 1)(c)(i) Requirement Timescale for action 01/07/07 2. OP8 12 (1)(a) 3. OP18 13 (3) (6) (7) (8) All relevant information concerning residents to be included in the care plan, including risk assessments and evidence of the involvement of residents and their representatives. That care plans accurately reflect resident’s care needs including any dressings and promote person centred care with personal choices and preferences being recorded to ensure residents receive appropriate care. Nutritional assessments to be 01/07/07 completed for all residents and linked to the care plan. That suitable risk assessments are completed in all areas of risk and cover the use of bedrails and risk of falls to promote resident safety. That the home provides a 01/07/07 safeguarding vulnerable adults (adult protection) policy and procedure and suitable training is provided to all staff to ensure residents are protected from all forms of abuse. DS0000068670.V336917.R01.S.doc Version 5.2 Evergreen Page 24 4. OP29 19(1) 5. OP30 18(1) 6. OP38 13 That the registered person 01/07/07 operates a thorough recruitment procedure that includes obtaining up to date photographs and confirmation of each staff members identification. That all staff receive induction 01/08/07 training and a rolling programme of training that provides them with the necessary skills to meet the needs of residents living in the home. That suitable individual and 01/07/07 environmental risk assessments are completed and responded to. That staff receive regular training on all aspects of health and safety and appropriate checks and certificates are retained within the home. 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 DS0000068670.V336917.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Evergreen DS0000068670.V336917.R01.S.doc Version 5.2 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. 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!