Inspection on 24/05/07 for Evergreen

This inspection was carried out on 24th May 2007.

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

The inspector 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 25/05/06

Evergreen 30/12/05

Evergreen 15/06/05

Evergreen 18/11/04

Evergreen 05/05/04

Evergreen 06/01/04

Evergreen 12/03/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Evergreen 55 Barrow Road London SW16 5PE Lead Inspector Lynne Field Unannounced Inspection 24th May 2007 10:00 Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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 DS0000022799.V338851.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 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 DS0000022799.V338851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Address 55 Barrow Road London SW16 5PE 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) 0208-677-4273 0208 677 4273 info@janeshouseltd.co.uk Jane’s House Limited Mr Atmah Victor Barsati Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 Brief Description of the Service: Evergreen residential care home provides accommodation and support for up to three adults who have support needs due to enduring mental health difficulties. At the time of this inspection there were no vacancies. The service is located in a former private house, which is sited in a quiet residential street and is indistinguishable from other houses in the street. The home is situated close to shops and amenities and has good access to public transport. The registered manager owns the property and also owns two other small homes nearby. During the inspection it was evident that the home has been well maintained and offers a homely physical environment for service users. It is laid out over three floors. The ground floor has a staff office, kitchen/diner, and a large communal lounge area. To the rear of the home there is a large garden. The first floor has the service user bedrooms, a toilet, and a bathroom with shower facility and toilet. The upper floor has sleeping accommodation for staff. The home provide information to potential service uses via their service uses guide, statement of purpose and their website. Visits can also be made to the home. CSCI inspection reports are available in the communal areas. The deputy manager said the current fees payable is in the range of £320.00p to £450.00 per week. There are additional charges made for toiletries, hairdressing newspapers and holidays. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out on the 24th May 2007. The deputy manager was present and took part in the inspection process. The inspector spoke to the deputy manager about how the home was developing and systems that are in place to ensure the residents are given the service they want and need. During a tour of the home the inspector met and spoke to two of the three residents, the third resident was out for the day. The inspection included a tour of the home, garden and the examination of records on care plans, medication records and the complaints book. Residents came and went during the inspection and the inspector was able to observe that the interaction between staff and residents was friendly and respectful. Residents have their own bedroom, and access to a range of homely communal areas. Appropriate professionals have been consulted and adaptations are being made to meet residents’ changing needs. What the service does well: Residents are regularly consulted about decisions that effect them, and are supported to lead as independent a lifestyle as possible. Residents reported being listened to and having no complaints. They felt able to complain if they needed to. Case files are held at the home in respect of each resident, which reflect their changing needs. Residents are encouraged, have opportunities and are supported to enable them to maintain appropriate lifestyles both within and outside the home. Contact with friends and family is supported and encouraged. Personal support is provided appropriate to their needs and wishes, and health care needs are comprehensively addressed. Residents are involved in choosing and preparing individual meals, which is good practice. They are being consulted about their final wishes, which promotes respect. The home is attractively furnished and decorated in a homely and comfortable style. Service users have spacious bedrooms, which they can personalise, and access to a range of communal areas. The home was clean to a high standard and well maintained. The kitchen needs some improvement. There are sufficient staff to meet residents’ needs. There are good and appropriate relationships between staff and residents. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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 DS0000022799.V338851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and services users’ guide needs to contain all the information required in schedule 1 to help the residents make an informed decision about the home. There is a policy of fully assessing all residents prior to admission. All the residents have a contract of term and conditions. EVIDENCE: The inspector checked the statement of purpose and service users’ guide and discussed with the deputy manager. Work is still needed to comply with the requirement that was left at the previous inspection in May 2006. The service users’ guide has a section on complaints but should have information about how to contact an independent advocate for support if required. The home has had no new residents since the last inspection and all residents have lived at the home for several years. The home has a policy of obtaining a full assessment of the prospective resident’s needs and will also complete their own assessment. Prospective residents would be encouraged to visit the home prior to admission. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 9 All the residents at the home had a contract of terms and conditions in their file. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in place and residents are supported to make decisions and risks in their lives. Risk assessments are in place but they need to be more detailed as to how the risk is managed and what is done to reduce the risk. EVIDENCE: The inspector looked at all three care plans. Case files seen contained daily records, monthly evaluations, care plans and minutes of review meetings. These provided evidence that residents’ needs are assessed and kept under review. . These had sections for any identified needs, the objectives and actions required to meet it. These are evaluated after six months. One resident, who is over sixty five years of age, has her care plan evaluated every month. The deputy manager said that they were in the process of reviewing the care plan format to include more information about resident’s needs and Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 11 how they wanted their needs to be met. The inspector was told the key worker goes through the daily records and other information and this will be used to draw up a new care plan. One resident had recently had their annual review with the social worker, other professionals and the staff other home and the information from this review was being included in the care plan. There were risk assessments in place and there was information around issues to do with behavioural issues or what to look for if there was deterioration in the person’s mental health and what actions to take. The home is reviewing the format and it is included it in the care plan. Risks are reviewed annually but these need to be more specific to each resident and include information about how the risk can be reduced. A requirement is given about this. The inspector met and spoke to two residents during the inspection. Both said they went out for walks or took part in activities they enjoyed. They confirmed to the inspector that they could come and go freely as they had front door keys. They are able to choose when to get up/go to bed, and reported that they are regularly consulted and involved in decision-making. Another resident was out for all of the time of the inspection. The inspector was told he was very independent and came and went as he pleased. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents engage in appropriate, enjoyable and fulfilling activities and mix with the general community. Residents are actively encouraged to keep in touch with friends and family and develop appropriate friendships. Residents’ rights and responsibilities are respected. EVIDENCE: On the day of the inspection the inspector met two residents, one had just returned from shopping. The third resident was out for the day and the inspector was told he would be back in the evening. They confirmed that they choose their activities. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 13 All the residents had different daily routines and interests. One resident spends their days mainly out of the home pursing his own interests quite independently, travelling on public transport using their bus pass, another spends more of their time indoors, but going out on their own for walks in the local area. One resident is exploring options with regard to further volunteer work and their interests around music as well as beginning to think more about whether they might look further at issues around moving on in the future to more independent accommodation. This resident has a girlfriend who he sees regularly. The inspector was told she sometimes stays at the home for the weekend. The home has offered residents holidays, but report that residents have not been interested with this offer. One resident says he goes on holiday with his girlfriend and prefers that. As all the residents are individuals living in the same house, not necessarily friends, they have their own ideas around what sort of holiday destination they may like and this is being explored with residents and the multi- disciplinary team. All the residents either do their own shopping or are supported to shop with a carer accompanying them. Residents can cook for themselves and if needed will be supported in the kitchen. The home does not have a menu and residents decide on the day what they want to eat and are encouraged to eat a healthy diet. One resident cooks most of her meals and has been losing weight to assist mobility. Another resident might choose one thing to eat in the morning but by the evening he has changed his mind. The staff have learnt to let him choose what he wants to eat when he comes back from his day out. The home has a visit from the activities organisers two days a week. The home does not have a weekly programme; all activities are very much centred on individual resident’s wishes and choices. The deputy manager said that there was however a routine around some aspects of the home, i.e. residents had particular days when they might do their washing with the support of staff if needed. The home will organise group trips out at times and invite residents to barbecues etc. at a nearby home run by the organisation. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in ways they prefer and their health and emotional needs are met. Residents are protected by the homes policies and procedures for dealing with medicines. Residents are consulted about their final wishes and the home is sensitive about how it does this. EVIDENCE: The residents’ files and care plans give information about residents’ health needs. The deputy manager told the inspector that all the residents have lived at the home for a number of years and the staff support the residents to maintain their physical and emotional health. The member of staff told the inspector that the residents are fairly independent with regard to personal care. One resident who developed a mobility problem, has been assessed by the occupational therapist and has been provided with bathing equipment. To Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 15 help her mobility, she has been encouraged to lose weight and this is being monitored on a weekly basis and is now stable. Staff support residents with personal hygiene by encouragement rather than providing direct physical care. The files seen by the inspector confirmed residents are in contact with various health professionals including care coordinators, psychologists and social workers. The deputy manager said they felt that they were well supported by other professionals and could discuss problems or issues with them if they needed. The home has begun gathering information around residents’ wishes and views regarding aging and death. One residents’ file contained more information than two of the others. The deputy manager said that they are looking at how best to discuss this issue further with residents as it was a very sensitive issue. The home has one resident who self medicates and travels independently to a clinic once a fortnight to receive injections. They were managing their own medication prior to coming to the home and continued to do this after they moved into the home. They collect their medication from the pharmacy and keep it in a lockable drawer by their bed. The home has a list of the person’s medication and the resident tells the home if their medication has changed. The two other residents are supported with their medication. The home have introduced a running total for the amount of medication they have left for each resident to ensure that they have the correct amount and this corresponds to the medication signed for from the pharmacy. The inspector checked one residents’ medication with the deputy manager and it was found to be correct. All medication coming into the home and medication that is not required is recorded in the medication book. Medication not needed is retuned to the pharmacy for disposal and this is recorded in the book. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents said they were listened to, and had no complaints. The home has an appropriate complaints procedure and the home has a copy of the local authority adult protection guidelines. EVIDENCE: The home has a complaints procedure. There have been no recent complaints. The complaints book is on display in the hall for residents or visitors to look at or write in. The home has information on the protection of vulnerable adults. The home has a copy of multi-agency procedure that it has obtained since the last inspection. The member of staff spoken to was aware of issues around the protection of vulnerable adults. The deputy manager said all staff has had training in adult protection since the last inspection in May 2006. The home has a policy regarding the protection of the resident’s finances. One resident has his money dealt with through his solicitor and the inspector saw copies of letters on file about this. The home keeps records of money spent by the residents and the resident signs this. As part of the inspection the residents’ money files were inspected and they were in order. One resident manages his own money, independently. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 17 The member of staff said the resident’s have meetings that are held in the home, and minutes are taken. Copies of these are kept on file. These covered a range of issues including meals, answering the phone and taking messages, planning activities, trips out, and the garden. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a pleasant environment, that is homely and well decorated. The kitchen and dining area are in need of redecoration and refurbishment. Residents have had relevant assessments have been provided with specialist equipment to help them keep and promote their independence. EVIDENCE: The home is situated in a Victorian house in a residential street. The inspector was given a tour of the home. There is a communal sitting room with French doors leading to a pleasant and well-maintained garden. There is a kitchen with dining area to the rear of the ground floor. The kitchen is shabby and would benefit from a total refurbishment. The kitchen units are broken and the worktops were chipped. Areas of the ceiling were coming away from the walls. The inspector noted the wallpaper looked old and the paintwork was chipped. It was brown and stained. There was large damp area where the paper was Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 19 coming away from the wall and it looked black in parts. The deputy manager says this has happened because of poor ventilation when the tumble dryer is being used. He said the wallpaper was about ten years old. The kitchen door did not shut properly and needs to be replaced. The deputy manager said the fire service had been in and made a number of recommendations. See Standard 42. The panel on the door to the cellar was broken. This needs to be replaced. The front room on the ground floor is used as an office. There are three residents’ bedrooms on the first floor, a bathroom and WC and a separate WC on the same floor. The home is furnished in a homely and attractive manner, with an upright piano and a TV in the sitting room. The home has pictures, ornamentation, and plants in all the communal areas. The effect is very homely, with an atmosphere as a family home. Residents bedrooms have been personalised. Two are quite large with room for a settee in one, which the resident has just purchased. One resident has a telephone and a computer in their room and had applied to have an Internet connection installed. They have a small fridge and a kettle and are able to make themselves and their guests snacks and drinks independently. The third bedroom is small, but the resident spoken to said they were quite happy with their room and in fact spent a fair amount of time in it. Although the room was redecorated in the last three years, some of the paper is coming away from the walls and looks shabby. The home would benefit from being redecorated. The inspector noted the carpet was spotted with white stains. The deputy manager said this happens because the resident likes to do her own cleaning and wants to keep her independence by doing her own cleaning. The bathroom has a large bath with a bath seat in it and a grab rail for the resident who has some mobility problems. This was put in after the resident had an occupational assessment when they were experiencing difficulties getting in and out of the bath safety by herself. The inspector was told by the deputy manager, “the resident was very independent and liked to do as much for themselves as possible”. The house has a cellar where food and other items are stored. This was generally well set out with items stored on shelving. The fridge in the kitchen was replaced as required. The home has fitted a thermostat on to the hot water cylinder outlet pipe, so hot water to all the hot water taps are controlled to ensure that hot water delivered to the taps is not above 43 degrees centigrade. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and residents would benefit from a full induction and foundation programme during the first six weeks and then six months of their employment. It would be good practice to renew the CRBs of staff who have been employed at the home for more than three years. EVIDENCE: The staff rota was inspected and confirmed the number of staff on duty was correct. The home has one member of staff on duty during the day and one sleeping member of staff at night. The deputy manager, who lives upstairs, works as the sleeping night worker. The inspector was told that should a resident need to be escorted to an activity or an appointment for some other reason, they will arrange for another member of staff or the activities organiser to act as an escort. This was reflected on the rota seen by the inspector. The manager was included on the rotas inspected. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 21 The inspector spoke to the one member of staff who was on duty at the time of the inspection. They said the management of the home were very supportive and confirmed they had gained NVQ level two. They said they were working towards NVQ level 3. They said all staff of the home were in the process of taking a course in Nutrition and Health run by Croydon College. They said they had been on a number of other courses such as POVA and Medication and Mental Health. They said they had regular supervision and the files inspected contained evidence of regular supervision and supervision notes that had been signed by the member of staff and the registered manager. Two staff files were examined and included one new member of staff to the home. These included copies of the application forms, two written references, a signed copy of their contract stating terms and conditions and identification. All files checked had CRB checks. The deputy manager said they would not start a member of staff to work in the home unless they had been CRB checked. All staff had copies of CRBs on file. The inspector noticed several staff who have been employed by the home, had CRBS that were three or more years old. It is good practice to renew these every three years to keep them up to date. The home has over 50 of their care worker qualified to level 2 NVQ or above. There were copies on the staff files of the certificates issued for the courses staff had attended. Although there were copies of the induction training that was given, this was only about the home and health and safety issues and did not fully comply with “Skills for Care” level of induction. This needs to be addressed. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know the home is well managed and planned. The home needs to obtain the views of residents or other people that come to the home with regard to quality assurance. The door between the kitchen and the hall and stairwell needs repair. EVIDENCE: The registered manager and deputy manager are both in the process of completing an NVQ level 4. The deputy manager was able to demonstrate an in depth knowledge of the needs of the residents and the routines in the home. Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 23 The home has not produced any written information around what they have done to monitor residents, relatives and other stakeholder views with regard to the quality of the service they provide. The home does not carry out surveys of relatives or other professional that visit the home but they have completed a number of self-monitoring reports and sent a copy to the CSCI office. The deputy manager said that they do not have residents meetings, in a formal sense. He speaks to people individually and feels that this works quite well. The home had a policy on health and safety and the inspector viewed health & safety records held in the home. The deputy manager confirmed that there were regular checks at the required intervals, by external contractors, for servicing the fire safety system, the boiler, central heating system and the emergency call system. Certification was in place regarding the Landlord’s Record of Gas Safety, Portable Electrical Appliance testing, and Certificate of Electrical Installation. A new fire alarm system was installed in May 05, the type of system was in line with the recommendation of the Fire department and a fire risk assessment and floor plan was completed. Records showed that regular checks of the fire alarm call points were made and that fire drills were conducted. The door to the kitchen is not a fire door, it is in a poor state of repair and ill fitting. The deputy manager said they keep it propped open for most of the day. He said when LFEPA visited they had recommended the door be fitted with an iridescent strip or be replaced. The inspector discussed replacing the kitchen door and fitting a door guard with the deputy manager, as it is a health and safety issue. Evergreen DS0000022799.V338851.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 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 X 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 X x 2 x Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4(1)(c) 4(2) Requirement The registered manager must ensure that all details required under Schedule 1 are included in the statement of purpose and service user guide. This is a repeat requirement the timescale of 01/06/07 was not met. The registered manager must ensure that all staff receive a full induction and foundation programme during the first six weeks and then six months of their employment. The registered manager must ensure that they produce written information detailing the action taken to monitor residents, relatives and other stakeholder views with regard to the quality of the service they provide. This is a repeat requirement the timescale of 01/06/07 was not met. The registered person must ensure that risk assessments are more specific to each resident and include information about how the risk can be reduced. The registered manager must ensure all fire and health and DS0000022799.V338851.R01.S.doc Timescale for action 30/07/07 2 YA35 18 (1) (c) (i) & (2) 30/07/07 3 YA39 24 (2) (3) 30/07/07 4 YA9 13 (4) (a) 30/07/07 5 YA42 13 (4) (a) & (c) & 23 30/07/07 Evergreen Version 5.2 Page 26 (4) safety issues are addressed. 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 Refer to Standard YA21 Good Practice Recommendations The registered person should continue the work began around exploring residents wishes with regard to the end of their life, death and illness The registered person should renew the CRBs of staff who have worked at the home for longer than three years. 2 YA35 Evergreen DS0000022799.V338851.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 DS0000022799.V338851.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. 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!