Inspection on 17/04/08 for Evergreen

This inspection was carried out on 17th April 2008.

CSCI found this care home to be providing an Adequate service.

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 13/03/09

Evergreen 16/05/07

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 Unannounced Inspection 17th April 2008 09:30 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.V361286.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.V361286.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) 01424 427404 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.V361286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2007 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 2008 range between £575- £750 per person per week depending on the room occupied and the level of care required. 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.V361286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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 key inspection that included an unannounced visit to the home and follow up contact with visiting health and social care professional. The allocated inspector spent approximately six hours in the home and was able to discuss matters with the registered manager who is also the responsible individual and director of the company that owns the home. During the assessment visits the inspector was able to spend most of her time meeting with the staff, residents and observing practice in the home. A brief tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, pre-admission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files, quality assurance systems and some health and safety records. The care documentation pertaining to three residents were reviewed in depth and the inspector ate a midday meal with the residents in the dining room. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from 9 residents (some of which had been completed by a relative) and 5 staff. The required Annual Quality Assurance Assessment (AQAA) was completed by the registered manager and returned when requested and was used to inform this inspection report. What the service does well: Evergreen Nursing Home provides a homely, comfortable and well-maintained environment for the people who live there. The home is clean and tidy. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 6 The registered manager and staff are committed in providing a good standard of care within a homelike and friendly atmosphere where communication between staff, residents and visitors is 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. Residents are fully assessed and individual plans of care are provided which sets out clearly each residents needs. Meals were very well received and complimented by residents and visitors to the home. Observations made during the inspection confirmed that staff are caring and respectful in their interactions with residents, and that their needs were being well attended to. What has improved since the last inspection? What they could do better: Clear up to date procedures reflecting best practice need to be implemented and followed with regard to the handling of medicines. In addition the home Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 7 needs to ensure that all the homes policies and procedures are up to date and make proper provision for the health and welfare of residents. The recruitment practice needs to be improved to ensure all the necessary checks are completed by the home before staff are deployed to work in the home. This will ensure robust recruitment practice is followed and safe guard residents. Although an improvement to the recruitment practice was required at the last inspection this inspection has identified shortfalls in other areas associated with recruitment and therefore have repeated this requirement. If shortfalls are noted in the future in respect of the recruitment practice in the home the commission may take enforcement action. Systems for quality auditing need to be developed with the questionnaires received being reported on and responded to and for interested parties being made aware of the findings and action taken. The AQAA needs to be used accurately as a quality-monitoring tool. Robust Health and Safety systems need to be adopted in respect of the homes environment and garden and should include regular risk assessments that are recorded and responded to. This is to ensure staff residents and visitors safety. 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.V361286.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People who use this service experience good quality outcomes in this area. 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 that all prospective residents are fully assessed by a competent person before admission and are assured that their needs can be met by the home. This process ensures that the home admits only those residents whose needs can be met by the home. Intermediate care is not provided at Evergreen Nursing Home. EVIDENCE: Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 10 The statement of purpose and service users guide was available in the office area along with the previous inspection report. A copy of the service users guide is included in the individuals care documentation and the registered manager said that each resident is supplied with a copy in addition. Although the statement of purpose and service users guide were found to be informative they still need to be further updated to provide accurate information, and all the required information as confirmed at the last inspection. The registered manager said that this was an oversight and would ensure that this shortfall is addressed. Required information includes the size of rooms in the home and the terms and conditions of residency. An assessment of the admission process included a review of the documentation used in respect of two recent admissions to the home. This demonstrated that prospective residents are fully assessed by the registered manager prior to any admission to the home being offered. Once an assessment has been completed the manager confirms in writing if the home is able to meet the assessed needs of the prospective resident, ensuring people can make an informed choice. Discussion with a resident’s relative confirmed that the admission process was smooth and well completed. Intermediate care is not provided at Evergreen Nursing Home. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 11 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individual plans of care set out resident’s personal, health and social care needs with risk assessments being used to inform this plan. Care is delivered in such a way that promotes and protects the residents’ privacy, dignity and individuality. Resident’s health care needs are met with the advice and support of community health care professionals. The homes practice ensures resident’s medicines are stored and administered safely. EVIDENCE: Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 12 The care documentation pertaining to three residents was reviewed as part of the inspection process. Each resident had a plan of care and these were found to be informative providing clear guidelines to staff, and promoted a person centred approach to the care with resident’s individual choices being recorded. The care documentation is based on a full assessment that covers the Activities of Daily Living and is informed by relevant risk assessment that include, pressure area damage, moving and handling, the use of bed rails, nutrition and the risk of falls. Records indicated that the plans of care are reviewed regularly and are usually completed in consultation with the resident or their representative. All residents spoken to were very satisfied with care provided at the home and this view was supported by the surveys received. One resident said how much she liked living at the home and how she hoped to become a permanent resident. A relative expressed her satisfaction and said ‘my father has improved greatly while being at the home. His health and strength are much better’. Visiting care professional were also positive about the care provided saying ‘the care is exceptionally good’ ‘the staff are responsive to the residents needs’. A selection of resident’s medicine records were reviewed and these were found to be accurate. A Monitored Dose System (MDS) is being used in the home and a local pharmacist is providing support and advice on this provision. During the inspection it was however noted that the registered manager had dispensed a group of residents medicines into labelled pots rather than administering directly from the MDS. Discussion took place around the best practice and the need for suitable medication procedures in the home. All medicines are stored securely within an appropriate storage area. Throughout the inspection visit staff were seen to be attentive and kind to residents and to speak to them in a respectful way. 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.V361286.R01.S.doc Version 5.2 Page 13 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are able to make a range of choices about their lives and are helped in maintaining links with friends, relatives and the community. Resident’s benefit from staff providing stimulation, which include leisure and recreational activities within the home environment. Residents receive a wholesome and appealing diet. EVIDENCE: The care documentation records resident’s social needs and the manager said this is going to be improved with the use of life histories/stories. She has also responded to feedback received from staff particularly identifying the need for more stimulation for residents with the provision of further games that can be used in group activity or individual interaction. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 14 During the visit it was noted that staff were spending time with residents engaging them with individual games or in group discussion. Music was also used in the home to entertain as an alternative to the television. A member of staff escorted one resident to a local shop and he clearly enjoyed this activity. Staff said that this was something that he liked to do most days regardless of the weather. Another resident said that she liked going to the local café with staff in the summer and went to a farm market regularly with her family. The home had also arranged an appointment with an aroma therapist for one resident to have some massage therapy. Visiting is very much encouraged and it was clear from observation and contact with relatives that people are welcomed and feel comfortable when they visit. Residents are encouraged to make decisions about what they do and how they spend their day. Residents meetings are held and the cook confirmed that the meal on that day was a specific request from residents, and included sausage rolls, baked beans and mashed potato. All feed back about the food was very positive with residents saying ‘the food is good’ ‘it is always good food here’. The evening meals are more flexible with the staff responding to individual choices made. Staff were seen to be assisting residents with their meals as necessary and residents had protective clothing with regard to their specific need. The dining experience was seen as a positive one although the dining room is rather small and would not be able to accommodate all residents at one time if they wished to use it. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good quality outcomes in this area. 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. Staff training and information in the home ensures that any Safeguarding Vulnerable Adult issue would be responded to appropriately when identified. EVIDENCE: The homes complaint procedure has been updated since the last inspection and records who will investigate any complaint. This procedure now needs to be readily available and replace any other procedure in the home. In addition staff need to be fully aware of the complaints procedure and have access to the complaint forms that are to be used. It was confirmed that the home has not received any formal complaint and neither has the Commission. All residents, relatives and care professionals spoken to about concerns and complaints said that they would be comfortable and confident in raising any concern with the registered manager, who they felt would deal with it. All staff have received training on Safeguarding Vulnerable Adults since the last inspection. This is now provided on a rolling programme. The registered Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 16 manager was aware that the local policies and procedures have been updated and had a copy of this new document. Although the home has a new procedure this needs to be cross referenced with the homes ‘Whistle blowing’ and include action that the home may need to take following an allegation like staff suspension or referral to the POVA register. The new procedure records that the manager will be contacted before reporting any allegation or suspicion of abuse to the appropriate authority. The practicality of this was discussed and it was agreed that a suitable person must be available to the home over the twenty-four hours or senior staff in the home must receive appropriate training to ensure that they report any allegation or suspicion to the appropriate authority in a timely fashion. The registered manager said that she would update the homes Safeguarding Vulnerable Adults procedures and it is recommended that it also includes relevant contact numbers for the police and social service. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 17 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 and 26 People who use this service experience good quality outcomes in this area. 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. 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 were found to personalised. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 18 During the tour it was noted that some radiators in the en suite rooms are not guarded. The radiators were not on and the registered manager confirmed that they have been isolated and could not be turned on by a resident or a member of staff. Associated risk assessments were not available with regard to these. The communal areas in the home are well used, however it was noted that the conservatory area became very hot later in the day. This needs to be monitored with suitable temperature control measure being provided to ensure residents are comfortable throughout the summer months. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 19 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 People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skill mix provides a competent and well-motivated staff team that meets residents health and personal care needs with a commitment to staff training. Residents are not fully protected by the home’s recruitment procedure. EVIDENCE: At the time of this assessment visit 15 residents were living at Evergreen, the residents have a mixed dependency some being mobile and not needing a high provision of nursing care. Staffing arrangements provide three care staff in the morning and two in the afternoon working along side either the manager or a registered nurse. Two waking staff work at night and a trained nurse is on duty 24 hours a day. The care staff are completing the domestic and some catering duties in the home and the current staffing arrangements and the dependency of residents accommodates this arrangement at the moment, although this needs to be kept under review to ensure suitable and appropriate staffing at all times. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 20 On examination of the duty rota is was identified that the registered manager is working very long hours covering all the day shifts apart from one, or one and a half days a week. The concern that she is working excessive hours was discussed and acknowledged. She confirmed that this was due to a recent staff retirement and that she was in the process of recruiting a registered nurse and an additional carer and anticipated that her hours would be reduced to a more reasonable level by the end of May 2008. All feedback received about staff working in the home was very positive and comments received included ‘My mother has been here for a year now and her progress has been amazing she is happy, talks more and looks great. I cannot thank the staff and management enough’ ‘the staff are wonderful’ ‘the staff are exceptionally good’. The staff surveys received reflected a very high satisfaction with the working arrangements and the excellent team spirit experienced at Evergreen Nursing Home. Staff training has been developed and the home has employed a registered nurse who organises and provides staff training in the home. Staff confirmed that staff training is given regularly and there was records held in the home that demonstrated an induction programme and a rolling programme of suitable training. The registered manager confirmed that there is a commitment towards promoting National Vocational Qualifications in the home. The AQAA recorded that 50 of the care staff have completed an NVQ in care at level 2 or above. The recruitment files pertaining to the three staff were reviewed as part of the inspection process. Whilst the documentation relating to two care staff was found to be satisfactory. The records relating to a registered nurse working in the home on nights in charge were not adequate. A Criminal Bureau Records and POVA check had not been completed by the home. In addition references had not been sourced from his current employment or most recent employer. This evidenced poor and not a consistent recruitment practice. This shortfall was raised with the registered manager and she assured that this person would not work in the home until the necessary checks had been completed. The registered manager confirmed this in writing following the inspection visit. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 21 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 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is approachable and provides a clear focus and leadership for the home however appropriate management procedures need to followed at all times. Quality assurance processes need further development to ensure that the Home is run in the best interests of residents. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally promoted and protected although practice in the home needs to be supported by appropriate risk assessments and policies and procedures. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager is also the responsible person and the director of the company, which owns the home. She is a registered nurse with experience of working with older people with nursing care needs. She has completed the Registered Manager Award and has been assessed in her work environment and is now awaiting her certificate, which she hopes to receive at the end of May. The registered manager provides a homely relaxed atmosphere whilst ensuring good standards of nursing care are maintained. She has an excellent rapport with residents and staff and was seen to be able to provide leadership and discipline when necessary. She is clearly highly motivated and it is important to her to provide a high level of care and has employed a registered nurse to provide professional advice and support. However recruitment practice in the home was found to be poor and she needs to ensure that a thorough recruitment procedure is follwed before any person is deployed to work in the home to safeguard residents living. Visiting professionals to the home were complimentary and spoke highly of the registered manager this view was further supported by all other feedback which refelcted that the home was being well managed. Staff felt well supported and able to approach her with any issue. Although the registered manager said that she had completed some quality monitoring surveys these had not been reported on and were not availble in the home. The AQAA had been completed and returned to the commission however this needs to be used more accurately as a quality assurance monitoring tool. An example of this is the fact that it recorded that all policies and procedures had been updated in 2007 when this was found not to be the case. The registered 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 with any extras being invoiced on a monthly basis. During the inspection visit it was noted that staff were moving resident around the home in wheelchairs without the footplates in place. This risk to residents was discussed with the manager who addressed the issue with staff immediately. Although individual risk assessments are documented environmental risk assessments are still not adequately recorded and the registered manager was reminded of her responsibilities under health and safety legislation. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 23 The AQAA confirmed that relevant safety checks have been completed in the home and records indicated that this was the case and that staff have received training on health and safety matters. A review of the homes policies and procedures confirmed that these were supplied by a training company and that most needed to be reviewed and updated to reflect the practice in the home and most current legislation and guidelines, the manager said that this was being progressed. Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 24 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 3 8 3 9 2 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 Evergreen DS0000068670.V361286.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13 (2) Requirement Appropriate medicine administration procedures need to be written and adopted in the home to ensure best and safest practice is followed. That the registered person operates a thorough recruitment procedure that ensures the fitness of people who work in the home. This should include the completion of a CRB and POVA check and securing two authentic/appropriate references for each employee. That a suitable quality monitoring system is maintained to ensure residents and their representatives views are taken into account and demonstrates ongoing review and improvement to the quality of care and services in the home. The registered person needs to ensure that all the homes DS0000068670.V361286.R01.S.doc Timescale for action 01/06/08 2 OP29 19(1) 01/05/08 3 OP33 24(1)(a)( b) (2)(3) 01/07/08 4 OP33 12(1) 01/06/08 Evergreen Version 5.2 Page 26 policies and procedures are up to date and make proper provision for the health and welfare of residents. 5 OP38 13 (4) The registered person shall make 01/06/08 arrangements to ensure areas accessible to residents are so far as reasonably practicable free from hazards to their safety. Appropriate risk assessments need to be completed recorded and responded to. 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.V361286.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone 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.V361286.R01.S.doc Version 5.2 Page 28 - 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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