Inspection on 22/06/06 for Evergreen

This inspection was carried out on 22nd June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 07/12/05

Evergreen 01/06/05

Evergreen 16/02/05

Evergreen 04/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Evergreen 290 Passage Road Brentry Bristol BS10 7HZ Lead Inspector Christopher Lewis Key Unannounced Inspection 22nd June 2006 09:30 Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 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 DS0000026590.V293903.R01.S.doc Version 5.1 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 Adults 18-65. 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 DS0000026590.V293903.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Evergreen Address 290 Passage Road Brentry Bristol BS10 7HZ 0117 9501791 0117 9501791 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) Treehome Ltd Ms Philippa Mary Waters Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 18 - 64 years with Learning Disabilities 7th December 2005 Date of last inspection Brief Description of the Service: Evergreen is owned by Craegmoor Healthcare. It is registered to provide accommodation and personal care for up to six people with a learning disability aged 18 - 64 years. A number of residents currently accommodated have complex needs, which can result in challenging behaviour. The premises are situated in a quiet residential area. It is a small house that blends in well with the immediate surroundings. There are some shops and local amenities in the vicinity. The home also has two mini-vans which residents use frequently to go out. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, conducted over 6.5 hours by Christopher Lewis, locum inspector. Evidence for the report on this inspection was gathered through interviews conducted with the home’s manager, members of staff on duty, discussions with residents, an examination of selected records and by direct observation. All parts of the home and its garden areas were seen. Unfortunately, the manager had been unable to distribute questionnaires for residents and their relatives to complete despite them being sent in good time from the Commission for Social Care Inspection. Some residents were spoken with on the day of the inspection; the views of relatives will be sought more formally at the next visit. What the service does well: What has improved since the last inspection? The recording of medication administered now appears to be more accurate thus helping to ensure resident’s safety. Work place risk assessments have been worked on though some may now need some updating. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 6 The floor covering in the upstairs bathroom has now been replaced and the room redecorated. A programme of refurbishments is on going though some areas in home still need some priority work. Formal supervision of staff now takes place at regular intervals thus helping to ensure that there is a consistent standard of care for residents. Policies on restraint now appear to be adhered to, though those policies need to be revisited on a regular basis to ensure staff remain aware of them and that the latest approaches are adopted to ensue resident’s safety. 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 DS0000026590.V293903.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The information that is available about Evergreen is well written and presented; however the statement of purpose still needs to be up-dated. Assessment and administrative processes are well established potential residents are able to visit the home to see if it meets requirements. Individual contracts are in place. EVIDENCE: A statement of purpose, service user’s guide and a glossy introductory leaflet are available which give a good general overview of what Evergreen provides. The service users guide is very user-friendly and accessible and presented in an easy to understand way. Full assessments of the needs of residents have been completed. Evidence was available from records and from discussions with the manager of Evergreen to show that the input of professionals outside the home is regularly sought if necessary to ensure that the residents, many of whom have been at Evergreen for some years, are well cared for. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 9 The manager explained that admissions are arranged initially through discussions between the manager and her supervisor. The home’s statement of purpose contains a flow diagram that fully describes the admissions procedure. The manager stated that any prospective new resident would be given the opportunity to visit the home on an introductory basis to see if the facilities met that person’s requirements and that an overnight stay would be arranged if felt to be applicable. Examples of resident’s individual contracts were seen which outlined the terms and conditions of their stay at Evergreen clearly and evidence was seen of family and professionals having been involved in the drawing up of such contracts. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Care plans are in place. Residents are encouraged to make decisions about their own lives and to be independent as far as their capabilities permit. Residents’ meetings are held regularly and records are kept securely. EVIDENCE: The files of four residents were looked at in detail and were very comprehensively completed, containing as they did full life histories and up-todate individual care plans. The support available from the clinical governance team for individual residents had been added to the care plans seen thus meeting a recommendation from the previous visit. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 11 The communication needs of residents were clearly recorded on file, as was detailed guidance for staff on how some residents should be approached and helped should they display behaviours that might put themselves or other residents at risk. These notes of guidance showed a sensitive and practical approach to such issues from the staff and management of the home. Consents to treatment were also on file. Residents’ meetings are held regularly in the home and minutes of these meetings were available. Several of the residents were keen to talk to the inspector about matters generally and no one showed any reluctance to speak about their true feelings about life at Evergreen and the way that the home is run. No complaints were received during the visit from those residents who were able to express an opinion. The staff aim to support residents in maintaining a safe and secure environment while also helping them to develop the skills where possible to live a more independent life-style. The home has a declared philosophy of empowering residents to take as much control of their lives as is within their capabilities. It was suggested by the inspector that, unless plans are made to seek alternative placements, management and staff will need to consider in more detail the fact that some of the residents are beginning to reach an age when they may need more and more help with their physical difficulties as they possibly become less able as they grow older. Comprehensive and updated risk assessments are in place for various activities and situations. The individual records of residents are kept secure and confidential within an office that is normally kept locked. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Staff are working hard to enable residents to participate in the life of the home and the local community and to develop appropriate relationships. The food on offer is nutritious and well balanced. EVIDENCE: Evergreen, in the words of the manager, “aims to help its residents lead interesting lives within a structured environment”. Residents continue to go out on a regular basis to such places as bowling alleys, pubs, cinemas and a nearby city farm. A number of residents are also registered on courses at a local college and they were keen to show their various certificates. One resident is particularly fond of football and is following the progress of the World Cup avidly. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 13 Previously declared plans to employ an arts and crafts worker for fifteen hours a week have now been shelved; activities are now the specific responsibility of one of the team leaders. This particular team leader, who is fairly new to the staff team in the home, showed a keenness to develop genuine and engaging activities for those who live at Evergreen and she was justly proud of recently being able to include one resident by his own choice more in the life of the home. This resident had previously chosen to avoid taking part in virtually anything that was organised. Residents who were spoken with talked excitedly about the various activities they were involved in. One room in the home is now taken over with arts and crafts pastimes. A session attended by three residents was taking place during the visit and the enthusiastic participation of those residents was very evident. The home has two mini-vans that are well used to take residents on trips out. Plans to build either a structure in the garden or a conservatory attached to the house to provide more room generally and especially for those who choose not to go out on many trips are still being considered. Contact with family is encouraged, particularly with several who live at the home having local connections and relatives living nearby. Conversations with the manager suggested a good awareness of people’s sexuality needs. Staff are also aware of this issue and would seek support for service users where appropriate. Staff appeared to be relaxed with those living at Evergreen and treated them with respect. When at one point the inspector spoke with member of staff in the garden and two residents joined them, these residents were carefully helped to join in the conversation in an appropriate way by that member of staff. Residents enjoy a snack at mid-day, usually soup and sandwiches with a larger meal taken in the evening, depending on what activities have been organised. Menus were examined and the food provided was seen to be of a good variety. The needs of one resident who does not eat meat were seen to have been catered for. The actual food intake of residents who might possibly be avoiding eating the food provided and thus not getting a sufficient balanced diet is now recorded. Food comment cards are also available. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Good systems remain in place to ensure that the health care needs of the residents are met. Policies are in place to deal with the illness or death of a resident though with an ageing and stable group these policies may need to be revisited to ensure they are adequate. EVIDENCE: Staff on duty were seen to be interacting in a sensitive and caring way with residents, one of whom was particularly distressed on the day of the visit. Residents approached staff with confidence and it was evident that good relationships had grown between residents and members of staff. Staff spoken with demonstrated a commitment to guiding residents in making choices and in providing a good standard of personal care overall. Discussions with the manager, her staff and residents and an examination of files showed that those that live at Evergreen receive the support they need as is outlined on their care plans. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 15 Residents are registered with a variety of local GPs including some who remain cared for by their “family” doctor as their relatives live very close to the home. All residents are registered also with dentists and opticians and the files revealed regular support for residents from other healthcare professionals such as psychologists, chiropodists and so on as and when necessary. None of the residents self-medicate at the present time. The medical administration charts appeared to be in order with no obvious gaps and system is in place to return any unwanted medication to the local pharmacy. Medication storage is through the “nomad” system. The individual care plans of residents contain information on the wishes of residents and their families should that resident die in the home. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Systems for dealing with any complaints by residents are in place. House meetings are now more regularly held. Procedures for the protection of vulnerable adults are established. EVIDENCE: The home has a clear policy on complaints and, as stated before, care plans outline how residents prefer to be communicated with. As several residents have difficulty in directly verbalising any problems they may be experiencing, such information on how they may express themselves is important. No resident who was able to do so expressed any discontent on the visit and two said specifically that they enjoyed living at Evergreen. No complaints were recorded since the last inspection though the manager felt that one from the next-door neighbours was certainly possible soon due to particularly high levels of noise following episodes of challenging behaviour from residents. One resident has had her medication changed recently and such issues have abated somewhat. A resident spoken with by the inspector had been experiencing difficulties a few months ago appeared happy now; indeed she showed the inspector around her room. The manager stated the resident, until recently, would not have wished to take part in any such activity. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 17 Concern was expressed in the past about the frequency of resident’s meetings being insufficient and them certainly not taking place weekly as stated in the home’s literature. Evidence in the form of meeting notes was seen to show that house meetings are now held monthly and it is to be hoped that at least this level continues to ensure that collective opinions are sought. The manager said that the area manager planned to hold a residence’s conference as a way of more actively including residents in decision-making. Policies are in place for the protection of vulnerable adults. The manager stated that, following comments made at the last inspection, staff in future will attend courses on POVA outside the home rather than receiving in-house training. A “reactive” strategy for helping each resident when they may exhibit challenging behaviour remains in place. These strategies are due for review shortly which the manager gave assurances would be done on time. This strategy details triggers that may lead to episodes of challenging behaviour and suggests actions that may be taken to reduce the likelihood of this. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Residents live in comfortable and homely surroundings. The home is clean and reasonably well kept though some parts are in need of redecoration. Some new furniture has recently been purchased. All bedrooms are single occupancy and personalised. EVIDENCE: Evergreen is set in a large house in a residential suburb of Bristol. Five of the bedrooms were seen, some with the inspector being shown around by the residents, others in the presence of the manager. One resident was in bed as he felt unwell and so was not disturbed. The rooms were personalised and contained pictures, televisions and DVD players except for one, which the manager said the resident chose to keep largely bare. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 19 Work that was required at the last inspection on the upstairs bathroom has now been carried out, the toilet having been moved and floor covering replaced. Two bedrooms have recently been redecorated though others remain to be re-furbished. The manager stated that a rolling programme of general redecoration is now in place. The doors to the bedrooms are particularly dark and uninviting and need replacing. The hall and stairway was also in need of attention and it is suggested that they are next on the list after the bedrooms. The hall, stairs and landing carpet is apparently fairly new but it is already in need of cleaning. New items of furniture have recently been purchased for the large garden in which the home is set giving residents more opportunity to spend time outdoors. Some new furniture has been bought for the shared living areas as well which has brightened the home up somewhat. The dining room has recently had two new cupboards fitted though as one resident pointed out, it needs could do with some repair and maintenance including the fixing of a broken skirting board. The kitchen is well equipped and fairly new though some more work apparently needs to be done to fit in a new cooker that has been ordered. The fly-killer is broken and needs to be fixed. All parts of the home were very clean. As stated before, relationships with some neighbours can be problematic although others are supportive of the work the home does. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. An enthusiastic and well-supported staff team looks after residents. Sufficient staff are on duty. Recruitment procedures are good though inductions are still not done within the required time frame. EVIDENCE: Staff duty rotas were examined and there are sufficient staff on duty at any one time to ensure the safety of the residents. The manager has begun to delegate more tasks to team leaders now there is a full complement of workers at that level and thus to ensue that clearer lines of delegation and accountability are in place. Good interaction between staff and residents was observed including those residents whose challenging behaviour might have caused some disquiet both to staff and other residents. Residents that were able to give an opinion made such comments as: “The staff are very good” and “They look after you”. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 21 Following comments at the last inspection about the manager needing to be aware of her organisation’s policy for recruiting staff from overseas, that policy is now prominently displayed on the office notice board. She also gave assurances that staff are now aware of the policies on restraint (and conversations with staff would appear to confirm this). Given the challenging actions that are sometimes exhibited by some residents of Evergreen, it is suggested that the manager should always keep up to date with current good practice relating to restraint techniques. The organisation’s recruitment policies overall appear to be sufficiently robust judging by the selection of staff files that were examined, with a generic application form in use and CRB checks done. The files also included certificates from recent training. However, the home is still failing to meet standards around new members of staff completing their induction within the timescales set by the organisation. Paperwork on the most recently appointed member of staff and discussions with that member worker proved that areas of her induction were still outstanding despite having been employed more than six weeks before the visit. The bulk of the work has been done; it was suggested that specific time is allocated in future to the important task of induction generally and specifically with the latest team member to get the job finished to ensure resident’s safety. Supervision records were examined and were seen to be satisfactory. Members of staff that were spoken with confirmed that they were regularly formally supervised. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,40,41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The manager exhibits an open style of leadership, though her training programme remains uncompleted. Policies and procedures to protect staff and residents are in place and the home is generally safe; however fire drills need to be carried out within the required time scales. EVIDENCE: It was noticeable that the home, notwithstanding the complex needs of several of the residents, has a generally relaxed atmosphere and the manager an approachable manner; for example a couple of the residents entered the office to join in the general interaction when the manager and the inspector were engaged in conversation and they were spoken with by the manager in a straightforward and respectful way. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 23 Similarly, as mentioned before, residents sought out the inspector and joined in the conversations in a very natural way when the views of staff were being elicited. Staff made no complaints about the management of the home, saying that relationships were comfortable and that they enjoyed working at Evergreen. As at the last inspection, the manager demonstrated a general commitment to staff and residents and a number of the requirements made at that visit have now been met. The manager has given past assurances that she will complete the Registered Manager’s Award. This has still not happened though the manager stated that she has been in discussion with senior executives about completing her outstanding modules. It was noted that policies are in place to cover whistle blowing, equal opportunities and so on and a “bill of rights” for residents is prominently displayed within the home. The resident’s records that were examined were up to date and appeared to be accurate. Work has been done on work place risk assessments though some now need to be revisited and updated. Fridge and freezer records were examined and were in order. Fire extinguishers and alarms are regularly checked; it was noted however that a fire drill is a couple of months overdue and this needs to happen quickly and it must be ensured that they do not to fall behind again. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 X 3 3 2 X Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 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. 2. Standard YA24 YA1 Regulation 16 4 Timescale for action The fly killer in the kitchen to be 08/07/06 repaired The Statement of Purpose to be 30/09/06 updated to include the specialist services available at the home. Ensure there is a rolling programme of redecoration of the residents’ bedrooms. 30/09/06 Requirement 3. YA24 16 4. YA42 23(4)(c)(iii) Fire drills must be conducted within prescribed time limits. 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA28 YA28 YA23 Good Practice Recommendations Hall, stairs and landing carpet should be professionally cleaned. Consider adding hall, stairs and landing to rolling programme of re-furbishment. Make sure policies and procedures on restraint are regularly updated. Evergreen DS0000026590.V293903.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 DS0000026590.V293903.R01.S.doc Version 5.1 Page 27 - 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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