Inspection on 26/07/06 for Evergreen

This inspection was carried out on 26th July 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 29/05/07

Evergreen 27/02/06

Evergreen 23/08/05

Evergreen 25/02/05

Evergreen 27/08/04

Evergreen 02/03/04

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

CARE HOME ADULTS 18-65 Evergreen 119 Wake Green Road Moseley Birmingham West Midlands B13 9UT Lead Inspector Kerry Coulter Unannounced Inspection 26th July 2006 10:00 Evergreen DS0000016727.V305654.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 DS0000016727.V305654.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 DS0000016727.V305654.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Address 119 Wake Green Road Moseley Birmingham West Midlands B13 9UT 0121 449 1016 F/P 0121 449 1016 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) TRACS Mrs Vicki Mae Morris Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home may accommodate a maximum of eight (8) service users with learning and physical disabilities, aged under 65 years. That the home can continue to accommodate three named service users who are over 65. That TRACS Evergreen apply for variation on behalf of future service users who reach the age of 65. That details regarding how the specific care and social needs of people over the age of 65 will be met must be included in the service users plan. Future admissions to the home are only considered for service users over the age of 45 years. 27th February 2006 Date of last inspection Brief Description of the Service: Evergreen is a large detached property, located in Moseley Birmingham. The home is close to a range of community facilities, which include shops, parks, places of worship, a library, leisure centre and public transport links. The home is set back off the main road in a small avenue that provides security and privacy from the road. The accommodation comprises of four bedrooms, an assisted bathroom, kitchen, lounge diner, office, laundry and conservatory on the ground floor. Work was underway at the time of inspection to develop an additional WC, to create a new laundry and to improve the size of two of the ground floor rooms. On the first floor are a further four single bedrooms, another bathroom, wc, and staff sleep in room. Work was underway to provide en-suite facilities in three of the rooms, and to upgrade the sleep in facility for staff. The home has off road parking, and at the rear of the home is a large deck area, and mature gardens. This home provides care and support for eight people with a Learning Disability or Acquired brain injury. The home aims to provide support to people over the age of 45. The pre inspection questionnaire completed by the Manager records that the fee levels range from £900 to £1645.49. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. Information used in the report was also collected by talking with the people who live in the home, staff on duty, family members and with one professional. A tour of the home was undertaken, and records about staffing, health and safety and care were also assessed. The unannounced fieldwork visit was carried out over seven hours. This was the homes key inspection for the inspection year 2006 to 2007. What the service does well: Evergreen is generally good at helping people live the lifestyle of their choice. This includes attending learning, leisure or staying in touch with people important to them. The staff at Evergreen are friendly and helpful. There are some staff who have worked in the home for a long time. The staff team is very stable, and people are supported by staff they know, and who are familiar with their needs. People can help with the running of the home. This may include assisting with their own laundry, making meals or drinks, or cleaning their room. Staff encourage people living in the home to help with household jobs such as the food shopping. All the people living at Evergreen have a single bedroom. These are all very different, and each person’s room contains the things that are important to them. Staff had written plans about how people need to be supported with personal care. These were very individual, and again promoted the person doing as much for them-selves as possible. The home has a strong manager. She has undertaken the required training, and is registered with the CSCI. She and the staff team work hard to make sure the service is focussed on the people who live in the home. The health and safety of people living in the home, staff and visitors are protected by regular testing of the fire alarms, electric and gas equipment. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Minor improvement is needed to the medication administration system to ensure residents get the medication they need, safely. Work needs to continue to ensure the home meets the needs of the residents in terms of its design. The manager must ensure staff get all the training and support they need to do their job and to support the people who live in the home. The Manager needs to ensure that when assessment of potential new residents is undertaken this includes an assessment of how they interact with existing residents to ensure everyone will get on well together. The Manager needs to ensure that where staff practice may impinge on residents privacy this is included in the care plan and that consent for the practice is obtained from the resident or their representative. Further work needs to be undertaken to ensure that satisfactory systems are in place to track the activities undertaken by residents and ensure that the activities are suitable and enjoyable. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 7 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 DS0000016727.V305654.R01.S.doc Version 5.2 Page 8 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 DS0000016727.V305654.R01.S.doc Version 5.2 Page 9 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, 4 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. TRACS offers potential residents and other people important to them a chance to visit the home prior to moving in. An assessment is undertaken prior to moving in, this is generally adequate but needs to include an assessment of how the prospective resident gets on with people who already live at the home. EVIDENCE: It was assessed at the last inspection visit in February 2006 that TRACS have produced a Statement of Purpose and Service Users guide. These were both informative, and written in an accessible format. The documents help the reader form an impression of the type of support and service offered at Evergreen. Discussion with the Manager indicates that these documents have recently been updated and new versions incorporating TRACS new logo will soon be sent to the home. The work undertaken with one resident prior to admission to the home was tracked. An assessment had been undertaken and a trial visit made to the home prior to the resident moving in. A report of the trial visit had been compiled, however it did not record how the prospective resident had interacted with existing residents. Records showed that the resident had been Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 10 fully consulted about the move and had been offered the opportunity of an overnight stay at the home but had declined this. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 11 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, 9 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need to support residents to meet their needs and achieve their goals. Residents are supported to make decisions about their day-to-day lives. Residents are supported to take risks within a risk assessment framework. EVIDENCE: The care plans for four residents were sampled, two in full and two in part. Plans sampled were detailed, and showed that the resident had been consulted about their health and lifestyle. The morning and evening routines had been written in such a way that it promoted the residents independence. Plans were up to date and detailed so that staff know how to support each resident and they have the information they need to support individuals in a consistent manner. It is good that an annual review is held with each resident, people important to them are invited to attend. One of these meetings was being held during the visit. It was held in private and attended by the resident, relatives, staff and a social worker. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 12 Observation of staff practice shows that they respect the decisions made by residents. An example of this includes one member of staff asking a resident if they could sit with them at the dinner table, the resident declined. This was respected by the staff who sat elsewhere. Residents were given lots of opportunities by staff to make decisions this included when to get up in the morning, when to spend time in their room, what to have to eat and drink and where they wanted to go out. Risk assessments for four residents were sampled. Requirements had been made at the last inspection to ensure that assessments were available for all identified risks to include residents going out independently and one resident being the subject of aggression from other residents. These risk assessments have now been completed. Assessments sampled were generally satisfactory and had been subject to regular review. Staff practice was observed to be in line with the assessment. For example, one assessment identified that staff needed to stay with them when they ate due to the risk of choking. It was observed that staff sat with this individual in their bedroom when they had breakfast and again at lunchtime. Where individuals had been identified as needing regular checks due to risk from epilepsy this was also observed to be done by staff. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 13 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): 12, 13, 15, 16, 17 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents generally experience a good lifestyle but record keeping and assessment of activities undertaken could be improved. Contact with family and friends are facilitated. The food provided is of a good quality, many of the dishes are home cooked. EVIDENCE: Sampled records and discussions with staff and residents show that a variety of activities are on offer to include community activities, consistent with any person of the residents age and gender. These included watching culturally appropriate films, visits to pubs, shopping, day trips, reading and cross words. One resident said that he enjoyed woodwork and makes items such as picnic tables and bird tables in the garden at the home. He has access to a shed where he keeps his woodworking tools. One resident went out food shopping during the visit, another sat in his room doing cross words. A new member of staff has been recruited who has previously worked as an art teacher. The residents have benefited from these additional skills as art sessions have been Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 14 introduced. The residents have done some lovely artwork on canvass boards and some of these have been put on display in the lounge area. Where residents had declined activities this had been recorded in their daily records. Sampled residents records did not always contain enough information to enable staff at the home to properly track the activities undertaken and if they had been enjoyed. For example some entries recorded that the resident had been on a ‘drive out’ but did not say where they had been, one entry recorded that the resident was waiting to go out on a day trip but then did not record if they had actually been. The residents and staff reported, and it was evident from care records that contact with people important to them is encouraged. This included people coming to visit at Evergreen, phone calls and people making visits to their family and friends. One relative spoken with said they were very happy with the care on offer at the home and that staff always kept them informed of what was going on. They did comment that some members of the family would find it easier to contact the individual resident by their own e-mail facility but that this was not available in the home. The Registered Provided should consider this request. Residents rights are generally respected, as stated earlier in this report staff were observed to offer choice to residents through out the visit. Where residents had chosen to lie in bed and not get up until later in the day this right had been respected. Where restrictions had been place on individuals, such as locking of the front door for their own safety the rationale for this was recorded in the care plan and risk assessed. One resident had a ‘peep hole’ in his door so that staff could check on them to ensure they were safe without disturbing them. There was no evidence within the care plan that the resident had consented to this practice. Staff checking on this resident in this way without consent is an infringement of privacy, consent needs to be obtained for this practice. The lunch served was freshly prepared and well presented. It was positive to see residents and staff sat together to eat and a nice atmosphere was created. Daily records and menus sampled show that meals are varied and the required five portions of fruit and vegetables are offered daily. Alternative choices are available on the menu. One resident said that he tended not to eat from the main menu and often shopped for and cooked his own meals. Stocks of food available were observed to be satisfactory. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 15 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 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive personal and healthcare support in the way they prefer and require and their health needs are generally well met. The systems for the administration of medication require minor improvement to ensure resident’s medication needs are safely met. EVIDENCE: The morning routine was relaxed, and this had been undertaken at a time and in the way preferred by each individual. The inspector met with all of the residents accommodated, and they had all been supported to undertake personal care to a good standard. Residents were dressed in good quality clothes appropriate to their age, gender and the weather. Residents care plans sampled had very detailed morning and evening routines, detailing how they like their care needs to be met, and the areas in which they require support. The residents accommodated have some additional healthcare needs. At the last inspection it was identified that the epilepsy care plan for one resident required improvement, this has now been done. One resident is prescribed medication for pain relief, but at the last inspection a pain management plan was not available. This was observed to have now been completed. Records Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 16 sampled showed that residents had regular check ups with the chiropodist, dentist and the optician. Medication management was assessed. Medication is stored in a locked cabinet. Copies of prescriptions are retained so that staff can check the correct medication has been received from the chemist. Medication Administration Records (MAR) had generally been signed appropriately but on one day medication given to two residents had not been signed. Discussion with the Manager indicates that competence assessments are not completed for staff who administer medication. It is therefore recommended that these are developed and completed for staff on an annual basis or following any medication administration error. Where residents are prescribed PRN (As required) medication a protocol is in place stating when, why and how this should be given. As required at the last inspection these had been reviewed to ensure the guidance was up to date. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 17 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, 23 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents views are listened to and acted on. Arrangements are generally sufficient to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: The CSCI has not received any complaints regarding this home since the last inspection. The home’s own complaints log and discussion with the Manager indicate that the home has not received any complaints since the last inspection visit in February. A complaints procedure is available along with a complaints leaflet. This information is also available in an audio tape format for residents who are unable to read. One relative spoken with said they had not had any reason to make a complaint but if they had they were sure the Manager would respond appropriately. At the last inspection it was identified one resident who had previously been subject to attacks by other residents accommodated did not have risk assessments or strategies to address the known vulnerability of the person. Discussion with the Manager and sampling of records shows that these have now been developed. It was also identified one resident could be vulnerable when accessing the community without staff support. It was required this area be explored and underpinned with a risk assessment, this has been done. Notification was received from the home that physical intervention had been used to protect one resident from harm. Records available in the home had been appropriately completed for this incident. Discussion with staff indicates Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 18 that physical intervention is rarely used and is only a last resort. Sampled staff records showed that they had done refresher physical intervention (Studio III) training in February. Adult protection training is also undertaken by staff as part of their induction and then refresher training. The training booklet showed the content to be satisfactory, but the training schedule records that this training should be 1 hr in duration. A period of one hour is a very short time to cover the important topic of adult protection and prevention of abuse. It is suggested that the duration is increased so that staff have sufficient time to digest all the information and have plenty of time to raise any questions or discuss any issues that need clarification. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 19 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, 26, 27, 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. TRACS is working hard to improve the accommodation at Evergreen to ensure that residents are provided with a comfortable and homely environment. EVIDENCE: Evergreen is an adapted domestic property, and from the outside is not distinguishable as a care home. At the time of the last inspection visit in February work to develop and improve upon the premises was underway. The work scheduled included the improvement of three ground floor bedrooms, the addition of three en suites to first floor bedrooms and a new laundry. The work to increase the space of the three bedrooms has been finished and en suites have been added to three bedrooms upstairs. The relative of one resident spoken with at the visit said they were pleased with the improvements made to the premises. A laundry has also been added to the home, this still requires new floor covering. Whilst this room is very small and not ideal for use by residents who use a wheelchair staff said it was a vast improvement as previously they had been having to take laundry to the local launderette. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 20 The ground floor bathroom has had a new shower cubicle installed so that residents now have a choice of a bath or shower. Unfortunately the only toilet on the ground floor is located in this bathroom. Discussion with staff indicates that this can be inconvenient for residents who want to use the toilet and have to wait when someone else is having a bath. The Manager said it is hoped to alleviate this problem by installing another en suite bathroom in one of the ground floor bedrooms. Since the last inspection a shower has been installed in the staff sleep in room. Staff spoken with said they had found it very beneficial to have a shower. It has been identified at the previous inspection that the kitchen cupboards, shelves and doors were all very worn, and it was required replacement of this be scheduled in the medium term. The Manager said that Tracs did intend to do this but that a date had yet to be scheduled. When work is done to refurbish the kitchen its design needs to meet the needs of residents who use a wheelchair as one resident accommodated is a wheelchair user. Not all residents bedrooms were observed, some residents said they did not want the Inspector to go into their room. Bedrooms seen were personalised and décor was of a satisfactory standard. The home was clean and free from offensive odours. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 21 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): 32, 33, 34, 35, 36 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing and their support and development are generally sufficient to ensure that an effective staff team supports residents and meets their individual needs. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: It was noted that both staff and residents appear comfortable in each other’s company and enjoy a good general rapport. Support to residents is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Nine staff have completed an NVQ in care (53 ), this just meets the standard of having 50 staff trained. The number of staff on duty at the time of inspection was ample to enable residents to access the community, and to receive the level of support and supervision required. At the last inspection the Inspector raised concerns regards staff levels at weekends, when there were sometimes three staff on duty all working a long day. The staff are entitled to a one-hour break, which resulted in the number of staff available dropping to two, for three hours during the day. At this visit staff spoken with said that staffing levels had recently increased to four staff, in part due to the admission of a new resident. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 22 Staff generally felt these numbers were satisfactory to meet residents’ needs. Observation of the homes rota for July showed that a minimum of four staff are on duty. The recruitment files of three staff were sampled. These contained all the required information to show that a robust recruitment process had been followed. This is an improvement from the previous inspection when several files had missing information. The staff training matrix for the home was sampled. This shows that staff have received most of the training they need to meet residents needs. As stated earlier in this report staff receive training in physical intervention and adult protection, but it is recommended that the duration of the adult protection training is extended. Recent training undertaken by staff has included fire, nutrition and cultural awareness. The matrix showed that only four staff had received manual handling training, this will need to be arranged for staff who have not done it, or need a refresher. Staff spoken with said they were satisfied with the training on offer. A new member of staff spoken with said they had done an induction to the home and had worked ‘shadow shifts’ for a few weeks where they were extra to the staff on duty. They had also completed most of their mandatory training and were booked to attend physical intervention and adult protection training. Staff records sampled showed that staff had received regular, formal, recorded supervision sessions with their line manager. In these sessions they had discussed the needs of the residents and how they were supporting them and identified any training and development needs that would help them in their role. Regular staff meetings also take place. Staff said that a recent staff strategy day had been arranged to discuss areas for improvement and any staff ‘niggles’. Staff felt this had been very useful. As a result of the meeting one of the ideas to introduce a staff and resident suggestion box had been introduced. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 23 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, 39, 42 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s views underpin development by the home. Health and safety is generally well maintained. EVIDENCE: The manager at Evergreen is very resident focussed, and endeavours to provide a well run home. Systems are in place to assure quality. This includes monthly visits to the home by a service manager who completes a report. Audits are carried out periodically to include health and safety, financial and an audit called ‘first impressions’. Resident feedback on the service is also sought on an annual basis and via the recently introduced suggestion box Staff test the fridge and freezer temperatures daily and records showed that these were within the limits for safe food storage. In house checks of the fire Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 24 alarm, emergency lighting and hot water delivery temperatures had been undertaken. Evidence that the fire, electrical, gas and lifting equipment had been serviced as required were also available. Fire drills have been undertaken. It was recommended that the procedure for evacuating the home at night be practised with staff and residents, this was not assessed at this visit. Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 25 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 3 2 2 3 3 4 X 5 X 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 X 26 3 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1,a) Requirement The pre-admission assessment undertaken prior to offering a new resident a place in the home must take into account the existing residents at the home. Ensure adequate systems are in place to track the activities participated in by residents and outcome of activity. Ensure consent is obtained from residents where ‘peep hole’ is in use, and documented in plan of care. Ensure that medication administration records are signed when medication has been administered. Plans for the upgrading of the kitchen units, and worktops must be scheduled, and undertaken. Previous requirement but date not yet passed 01/12/06. New floor covering needs to be fitted in laundry room. Ensure adequate number of toilets are available on the DS0000016727.V305654.R01.S.doc Timescale for action 30/09/06 2. YA12 12(1) 16(2,m-n) 30/09/06 3. YA16 12(1) 15/09/06 4. YA20 13(2) 15/09/06 5. YA24 23(2)(b) 01/12/06 6. 7. YA24 YA24 YA27 23(2)(b) 23(1)(a)(2)(a) 30/09/06 01/02/07 Evergreen Version 5.2 Page 27 8. YA35 18(1)(c) ground floor to meet needs of residents. Ensure all staff have received training in manual handling. 30/10/06 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 YA11 YA15 YA20 Good Practice Recommendations It is recommended the reason service users decline activities be explored. Previous recommendation. Not assessed at this visit. Investigate if residents can be provided with their own email address at the home. Medication competence assessments- It is recommended that these are developed and completed for staff on an annual basis or following any medication administration error. A period of one hour is a very short time to cover the important topic of adult protection and prevention of abuse. It is suggested that the duration is increased so that staff have sufficient time to digest all the information and have plenty of time to raise any questions or discuss any issues that need clarification. It is recommended that the action to be taken in event of a fire (Fire drills) be explored with night staff, and a record of such maintained. Previous recommendation. Not assessed at this visit. 4. YA23 YA35 5. YA42 Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Evergreen DS0000016727.V305654.R01.S.doc Version 5.2 Page 29 - 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. 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