Inspection on 02/06/05 for Evergreen

This inspection was carried out on 2nd June 2005.

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

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

Other inspections for this house

Evergreen 20/02/07

Evergreen 14/12/05

Evergreen 16/12/04

Evergreen 12/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Evergreen 526 Church Road Yardley Birmingham B33 8HT Lead Inspector Kulwant Ghuman Unannounced 2nd 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 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 e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Evergreen Address 526 Church Road Yardley Birmingham B33 8HT 0121 783 2080 0121 783 2080 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) Mr David Thompson Mrs Rebecca Hobbins Care Home 14 Category(ies) of Care Home registration, with number of places Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 December 2004 Brief Description of the Service: Evergreen is located in a quiet residential road in “Old Yardley” approximately four miles from the city centre. There are good public transport services close by and the home is within easy walking distance to local shops and community facilities such as Yardley old church and park. The accommodation is a converted three storey detached house offering accommodation to 14 elderly service users. The second floor is used solely by staff as an office and sleepingin facility. The accommodation comprises of three double and eight single bedrooms spread over the ground and first floors. A stair lift is available for ease of access. Bedrooms vary in size and are all comfortably furnished and individualised by the occupant. There are toilet and bathing facilities on both floors. Communal rooms are situated on the ground floor and consist of a large lounge leading to a wellmaintained rear garden and an adjoining dining room. Both rooms are nicely decorated and furnished. The laundry, kitchen and staff toilet are located on the ground floor. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors over one day during June 2005 and was the first of the statutory inspections for the home for 2005/2006. There were 13 residents in the home at the time of the inspection. During the inspection the inspectors spoke briefly to two residents, the manager and proprietor, toured the building and sampled some records. What the service does well: 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. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 No service user guide or statement of purpose was available for inspection at the home. It could not be determined whether prospective residents had the information required for them to make an informed decision about whether to move into the home. EVIDENCE: There was no statement of purpose or service user guide available in the home at the time of the inspection. The manager stated that she was reviewing the documents and would send a copy to the CSCI. At the time of writing this report these documents had not been received by the CSCI and therefore the requirements made at the previous inspections have been brought forward to this report. There had been no new admissions to the home since the last inspection therefore the other standards in this section were not assessed but they had been met at the previous inspection. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The social, personal and health care needs of residents, and how these were to be met was made clear to staff through the care planning documents. Relatives were involved in the reviewing of care plans. Residents were provided with medicines in a timely manner. Privacy in the home would be further enhanced by the provision of suitable locks on bedroom, bathroom and toilet doors. EVIDENCE: The care planning system used in the home was good with an assessment that covered all the necessary areas of daily needs. A care plan was formulated using this information which provided a good description of the residents’ care needs. Care plans were reviewed on a monthly basis with input form families where appropriate. There was a nutritional assessment in place and these had been linked into the risk assessment but the care plans did not say what actions were being taken to manage the risks identified. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 9 Health care needs of residents were being met and there were documented visits from the GPs, chiropodist and dentist. The district nursing service was accessed by the home for the provision of pressure relieving equipment. The home used the Nomad system for the administration of medicines. There were no controlled medicines in the home at the time of the inspection. There were only one or two minor issues raised during this inspection in respect of the administration of medication. There were a few of occasions where there was a gap in the medication records or the code ‘A’ had been used but the tablet was not in the nomad cassette. In addition, where directions for the administration of a medicine had been instructed over the telephone a second carer needed to check the changes and indicate that these were the instructions given over the phone. The staff must ensure that the instructions given by the GP, written up by the staff on the MAR chart and identified on the label provided by the pharmacist all tally. If there is a difference in any of the details these must be confirmed with the GP or the pharmacist. During the inspection it was observed that the sharps box was kept on a high shelf and was full. There was a potential risk that the box could fall and be a potential risk to the staff or residents. It was strongly advised that the sharps box was kept in one of the cupboards and arrangements made for its collection as soon as possible. In order to further enhance the privacy of residents’ locks on bedroom, toilet and bathroom doors must be suitable. It was observed that the hairdresser used the dining room and the inspectors were informed that the chiropodist also used the dining room. The inspectors accepted that there was a shortage of space in the home but in the absence of a medical or hair dressing room the hairdresser and chiropodist must be encouraged to use the residents bedrooms to promote privacy and dignity and minimise the risk of cross infections due to any fungal infections to residents’ feet. Instructions for staff on the walls indicating how care needs were to be met should be removed as this information is available on the care plans. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 There were a variety of activities on offer to residents for them to be involved in and the meals provided a good standard of nutrition and provided choices for residents. EVIDENCE: The manager informed the inspectors that there was a library service to the home every four weeks and audio tapes were made available to residents. There were progressive mobility, quiz, bingo and carpet bowls sessions organised in the home and there were examples of arts and crafts activities around the home. One of the residents spent time gardening and another went out regularly on ring and ride and shopping. Pub lunches were to be arranged during the summer. Residents were observed to be enjoying their lunch which was home cooked and well presented. One resident spoken with stated he enjoyed his food. There were choices available at all mealtimes. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The above standards were not assessed during this inspection. Requirements made at the previous inspection have been brought forward to this report. EVIDENCE: Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The home provided a comfortable environment for residents within the limitations of the structure of the building however, plans for improving the facilities needed to be pursued. EVIDENCE: The home was found to be clean, comfortable and generally well maintained. Rails had been added to the ramp at the front of the home. The communal space continued to be limited. The dining room space was quite restricted and needed to be increased. There was a walk-in shower facility on the ground floor. The flooring in this room had not been completed and the hot water was not restricted to 43 degrees centigrade. The bath and shower on the first floor had not been altered to provide another assisted bathing facility and the shower had not been disconnected. The decoration of the toilet on the first floor, where the old toilet had been replaced with a new one, was outstanding. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 13 There were bolts on the door of the bathroom and toilets that were not suitable as they could not be opened from the outside in an emergency and one was not in working order therefore privacy could not be guaranteed. There was a stair lift to assist residents to the first floor facilities and there was an emergency call system in place. Mobility aids such as zimmer frames and wheelchairs were available to residents. Bedrooms were comfortably furnished and appropriately personalised. Bedroom doors needed locks that could be opened by staff in an emergency situation. Some rooms did not have easy chairs however the manager had carried out an audit of bedroom furniture and discussed the shortfalls with the residents. There were not two bedside lamps in shared bedrooms. All bedrooms had a wash hand basin with a supply of hot and cold water except in one bedroom where there was no hot water. The manager was aware of this situation. There was adequate heating in the home and radiators were guarded. There was no sluice facility in the home. There were several bars of soap and disposable razors in the bathrooms and there was no wash hand basin in the toilet on the first floor. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staffing levels were found to be suitable to meet the needs of residents and continuity of care was provided for residents as there was little staff turnover in the home. EVIDENCE: The staffing rota showed that there were 2 carers on duty during the morning with an additional person between 8.30am and 10.30 am. During the night there was one waking member of staff and one on sleeping in duty. The manager needed to ensure that when the cook and cleaner were not on duty an additional carer was put on duty. The rota must show the roles being undertaken by the staff, times when the manager is assisting with care and the hours being worked by staff. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,37,38 The management of the home was good and health and safety was generally well managed providing a safe environment. EVIDENCE: The manager had been in the home for several years and continued to demonstrate a commitment to improving the home and the services provided. The home was well managed with the following issues being raised:1 A current certificate of insurance must be displayed in the home. 2 A current gas safety certificate must available for inspection in the home. 3 The hoist must be serviced or taken out of use. 4 A fire drill and fire training for staff needed to be arranged. 5 Safer storage of the sharps box. 6 Restriction of the hot water temperatures at the showers. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 2 2 3 2 2 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x x 2 2 Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 17 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1)(b)(c) Requirement The statement of purpose for the home must include all information as detailed in Schedule1 of the Care Homes Regulations 2001. (Previous time scale given 01/09/04. Compliance not checked at this visit.) The service user guide must contain all the information detailed under Regulation 5(1) of the Care Homes Regulations and National Minimum Standard 1.2. (Previous time scale given 01/09/04. Compliance not checked at this visit.) Risk identified must be included in the residents care plans to show how the risks are to be managed. All medication administered to the residents must be signed for. Changes in the directions for the administration of medicines must be checked and evidenced by two staff. The home must have appropriate storage for controlled medication. (Previous time scale of 01/10/04 not met) The manager must ensure that Timescale for action 14.7.05 2. OP1 5(1) 14.7.05 3. OP7 1.8.05 4. 5. OP9 OP9 13(2) 13(2) 14.7.05 14.7.05 6. OP9 13(2) 1.9.05 7. OP10 12(4)(a) 1.9.05 Page 18 Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 8. 9. OP10 OP18 12(4)(a) 13(3) 13(6)(7) & (8) 10. OP19 23(2)(d) 11. OP20 23(2)(e) 12. 13. OP21 OP22 13(4)(c) 23(2)(n) 14. 15. OP25 OP26 23(2)(p) 13(3) appropriate locks are fitted to all toilets, bathrooms and bedroom doors. (Previous time scale of 01/10/04 not met) The hairdresser and chiropodist must use the residents bedrooms. The manager must develop a policy and procedure on physical intervention, which is in line with codes of professional practice and recognised by relevant professionals. (Previous time scale given 01/10/04. Compliance not checked at this visit) The decoration of the toilet on the first floor, the flooring in the shower room on the ground floor and the hot water delivery to the wash hand basin in the bedroom identified must be attended to. The communal space at the home needs to be increased. (Previous time scale of 01/12/04 not met). An action plan on how this will be achieved to be forwarded to the CSCI. Shower on the first floor must be dismantled or a water temperature regulator fitted. The emergency call system should be of a type that the call is cancelled at the point from where it was made. Emergency call points must be accessible from all facilities. (Previous time scale given 01/03/05. Compliance not checked at this visit.) There must be bedside ligting for each resident in shared bedrooms. The manager must ensure that all bars of soap and razors are removed from communal areas of the home. 14.7.05 1.8.0S5 14.7.05 14.7.05 14.7.05 1.8.05 14.7.05 14.7.05 Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 19 16. 17. OP27 OP27 17(2) Sch 4(7) 18(1)(a) 18. OP29 19 Sch 2 19. OP30 18(1)(a) 20. 21. 22. 23. 24. OP37 OP38 OP38 OP38 OP38 25(2)(e) 23(2)(c) 13(4)(c) 23(4)(d) & (e) 23(2)(c) The staffing roster must show the roles undertaken by staff and the hours worked. The manager must ensure that an additional member of staff is on duty when the cook and cleaner are not on duty. The manager must ensure that all the documentation detailed in schedule 2 of the Care Homes Regulations 2001 is obtained for all staff. (Previous time scale given 01/08/04. Compliance not checked at this visit.) The manager must ensure that both induction and foundation training for staff is in line with the specifications laid down by the National Training Organisation and that evidence of this is kept on site. (Previous time scale given 01/09/04. Compliance not checked at this visit) A current certificate of liability insurance must be displayed in the home. The hoist must be serviced or taken out of use. (Previous timescale of 1.2.05 not met.) The sharps box must be safely stored and collected before becoming too full. The manager must ensure that a fire drill and training for staff is organised. A current gas safety certificate must be available for inspection in the home. 14.7.05 14.7.05 1.8.05 14.7.05 14.7.05 14.7.05 14.7.05 1.8.05 14.7.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Evergreen Refer to Good Practice Recommendations e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 20 1. 2. Standard OP10 OP26 It is strongly recommended that the instructions for staff on bedroom walls are removed. It is strongly recommended that a sluice facility is installed at the home. Evergreen e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ 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 e54_S16747_Evergreen_V232491_020605 - Stage 4.doc Version 1.30 Page 22 - 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!