Inspection on 23/06/05 for Evergreen

This inspection was carried out on 23rd June 2005.

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

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

Other inspections for this house

Evergreen 27/06/07

Evergreen 10/05/06

Evergreen 09/12/05

Evergreen 14/12/04

Evergreen 05/08/04

Evergreen 05/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Evergreen 2 Brandreth Road Mannamead Plymouth PL3 5HQ Lead Inspector Jane Gurnell Announced 23 June 2005 rd 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 D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Evergreen Address 2 Brandreth Road, Mannamead, Plymouth, Devon, PL3 5HQ 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) 01752 665042 Mrs Jacqueline Denise Tope Mr Roy Richard Tope Mrs Jaqueline Denise Tope Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Age 60 Date of last inspection 14.12.04 Brief Description of the Service: Evergreen is situated within walking distance of Mutley Plain shopping precinct in Plymouth. The establishment is formed from two terraced Victorian villas that have been internally combined. The home has a family atmosphere due to the efforts of the owners and the staff, and because the home can only accommodate sixteen residents at any one time this ensures a non-institutional atmosphere. The home has the category of OP (older person) and has neither of the specialist categories for the provision of dementia care or severe physical disability. The home specialises in creating a homely environment to meet the individual needs of each resident. Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over 4 hours on 23rd June 2005. Mr and Mrs Tope and Mrs Meerton, the owners and manager of Evergreen were present during the inspection and they and their staff team assisted the inspector throughout the inspection. The focus of the inspection was to consult with the residents and review the care planning processes and related documentation. The inspector spoke to 13 service users, toured the building and examined care records and other documents. What the service does well: What has improved since the last inspection? What they could do better: The hot water supply to the baths must be fitted with hot water control valves to reduce the risk of residents’ being scalding from water that is too hot. Mr and Mrs Tope should continue with their programme of fitting door locks to residents’ bedroom doors of a type that do not require a key from the inside and can be overridden by staff in an emergency. Mr and Mrs Tope may wish to consult further with the residents about menu planning. The laundry room should be cleared of items that are no longer required or that could be stored elsewhere. Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 6 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 D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 and 5 Thorough and comprehensive systems for admission allow residents and their relatives to be confident that their needs can be met. EVIDENCE: A Statement of Purpose and Service User Guide were available for prospective residents and provided a clear description of the services offered; a further information pack is available for residents and their families and provides information about local services and life at Evergreen. Assessments were undertaken to identify residents’ needs prior to admission and these were evident for 2 newly admitted residents. Residents said that they and their families had been able to visit the home before making a decision to move in. Many of the staff have worked at Evergreen for a number of years and have a great deal of experience: all staff receive regular training relating to the care needs of older people. Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 9 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 and 11 Residents health, personal and social care needs are being met and residents are treated respectfully. The home’s practices relating to medication administration protect the residents from risk. EVIDENCE: Residents said they could not be treated better and described living in the home “lovely” and “excellent”, saying it was like living in a hotel with nothing being too much trouble for the staff. Care plans detailed residents’ care needs and included risk assessments relating to activities of daily living, mobility and falls: these were regularly reviewed. The Dentist was visiting at the time of the inspection and confirmed that he had an excellent relationship with the owners and staff and was confident that residents’ health care needs were being met. Residents’ with terminal illnesses could remain in the home as long as the District Nurse and the care staff could continue to meet their needs: Mrs Tope had sensitively sought residents’ wishes regarding their care and funeral arrangements. Medication administration records were well maintained and medication was stored safely. Evergreen D52_D04 S3477 Evergreen V222016 230605 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, 13, 14 and 15 Social activities are managed well and provide interest for the residents. Meals are nutritious and varied. EVIDENCE: Leisure and social activities organised by external facilitators are planned several times a month: a list is provided on the notice board and the residents said that these were much enjoyed. Care staff facilitate spontaneous activities with residents according to the weather and their wishes, such as visits to the local shops and other places of interest. The freedom of residents to come and go is not restricted and residents are encouraged to continue with their hobbies and interests outside of the home. Relatives and friends are welcome. The Residents said that the meals were very good and provide a well-balanced diet. A number of residents requested that the set menu be changed a little more frequently. Evergreen D52_D04 S3477 Evergreen V222016 230605 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) 16, 17, 18 Complaints and suggestions from residents, relatives or other visitors to the home, are treated seriously. Residents are listened to and issues resolved promptly. EVIDENCE: Residents said that the owners and staff were very approachable and they were confident that any issues of concern would be listened to and dealt with. No complaints since the last inspection. A copy of the complaints procedure is available to all residents and visitors and detailed in the home’s Statement of Purpose and Service User Guide. The information pack provides a statement of residents’ rights and information about advocacy services. Staff have received training in issues relating to abuse and the protection of vulnerable adults and described the actions they would take should an issue of abuse be suspected. Evergreen D52_D04 S3477 Evergreen V222016 230605 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, 24, 25 and 26 Residents live in a pleasant, well-maintained home that is comfortable and warm and which provides sufficient facilities to meet their needs. EVIDENCE: All communal rooms and bedrooms were pleasantly decorated and furnished, reflecting the period of the building. Residents said that the home is always very clean. Residents are provided with a small safe to store valuables and locks are being fitted to bedroom doors. Radiators identified as posing a risk of burn injuries to residents have been covered. Staff check hot water temperatures before assisting each resident to bathe, however control valves must be fitted on baths and other hot water outlets identified as posing a risk of scalding to residents. The laundry room is used as a general store room as well and any items no longer required, or that could be stored elsewhere, should be removed to ensure the room can be easily cleaned. Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 13 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, 28, 29 and 30 Residents are cared for by well-trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment processes protect vulnerable residents. EVIDENCE: Residents described the staff as very kind and caring and confirmed they responded promptly to requests for assistance. Care staff are supported by catering, domestic and management staff. Mr and Mrs Tope, the owners, work in the home 6 days a week. A training programme detailed the ongoing training undertaken by staff ensuring that they have the skills to care for older people. Sixty-six percent of staff are qualified to at least NVQ2 with a further three staff undertaking training in NVQ levels 2, 3 and 4. Staff files contained application forms, written references, Criminal Record Bureau disclosures, and photographic identification. Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 14 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) 32, 33, 35, 36, 37 and 38 Residents live in a well managed home. The owners and their staff team strive to provide a homely, stimulating and safe environment that respects and protects residents’ rights. EVIDENCE: Residents said that they feel safe and secure in their home and that the home was well managed. Mr and Mrs Tope are available each day, including weekends and meet with residents and staff on a daily basis. Staff confirmed that they meet with the owners regularly to ensure that residents’ needs continue to be met and any issues dealt with promptly. Records confirmed that staff receive supervision to review their work performance and training and development needs. Sampling of service contracts indicated that equipment was being regularly serviced and well maintained. Fire safety training for staff was documented Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 15 and included unannounced fire training drills to ensure staff were aware of their responsibilities should a fire be discovered. Residents’ money held for safekeeping by the owners is fully recorded and audited. Formal consultation with residents occurs every 6 months and contributes to the owner’s quality assurance processes. Evergreen D52_D04 S3477 Evergreen V222016 230605 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 4 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 2 2 2 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x 4 3 x 3 3 3 3 Evergreen D52_D04 S3477 Evergreen V222016 230605 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 OP25 Regulation 13 Requirement Hot water temperautes must be controlled on baths and any hot water outlets identified as placing residents at a high risk from scalds. Timescale for action 31.12.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP15 OP24 OP26 Good Practice Recommendations The owners should consult with residents regarding menu planning. Door locks should be fitted to bedroom doors of a type that do not require a key from the inside and can be overridden by staff in an emergency. The laundry room should be cleared of items that are no longer required or that could be stored elsewhere. Evergreen D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 D52_D04 S3477 Evergreen V222016 230605 Stage 4.doc Version 1.30 Page 19 - 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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