Inspection on 27/02/06 for Evergreen

This inspection was carried out on 27th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 29/05/07

Evergreen 26/07/06

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 Alison Ridge Unannounced Inspection 27th February 2006 10:00 Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Evergreen Address 119 Wake Green Road Moseley Birmingham West Midlands B13 9UT 0121 449 1016 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.V285037.R01.S.doc Version 5.1 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. Date of last inspection 23rd August 2005 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 ensuite 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. Three service users are over the age of 65, and the home aims to provide support to people over the age of 45. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector undertook this visit over one day. Information used in the report was collected by talking with the people who live in the home, staff on duty, and from comments cards received from two service users, two from family members and four from professionals. A tour of the home was undertaken, and records about staffing, health and safety and care were also assessed. It is suggested that this report be read alongside the homes previous inspection report, of the visit undertaken in August 2005. The inspector extends her thanks to everyone who assisted with this inspection. What the service does well: Evergreen is generally good at helping people life 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. The staff respect the confidentiality of each person. The staff and service users prepare a lot of food from fresh, and the use of processed food is limited. The people living at Evergreen report the food is tasty, and varied. 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 persons room, contains the things that are important to them. The inspector met all five of the people currently living at Evergreen. They had all been supported to undertake personal care, and to choose clothes that were clean, well fitting and suited to the weather. 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. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 6 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, gas and lifting equipment. Two comment cards were received from people living at Evergreen, two from visitors, and four from Health and Social care professionals. Feedback about the care and support provided at Evergreen was generally positive. What has improved since the last inspection? What they could do better: Care documents, including the service users plan, and risk assessments were found to need some further development to ensure all the service users needs were being addressed, and that staff had clear information regards how to meet these needs. The system for recording and planning routine health care appointments requires review to ensure these are undertaken with the required frequency. The manager must ensure that records evidence staff were fully checked prior to starting work in the home. The number of staff available during staff break periods, at weekends when three staff are working a long day must be reviewed, to ensure service users safety and welfare. The building work on the premises needs to be completed, and re-decoration of the home will need to follow. One of the comment cards received reported that the home could be noisy, and that some people living in the home swore a lot. This wasn’t the inspectors Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 7 experience on the day of inspection, but it has been recommended the manager look at this to check everyone is happy. 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.V285037.R01.S.doc Version 5.1 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.V285037.R01.S.doc Version 5.1 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): TRACS have produced documents for potential new service users and professionals that give a good feel of the service offered at Evergreen. EVIDENCE: TRACS have produced a Statement of Purpose and Service Users guide. These are 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. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Service users plans contain detailed and personalised information. Where possible the service user has been involved in the drafting of the plan. Service users are encouraged to play an active role in the life of the home. Risks service users face, and present require further assessment and planning to ensure these are all well met. EVIDENCE: The individual plans of four service users were assessed in full or in part. The plan of one service user showed particularly good practice in helping the service user to live the lifestyle of her choice, and to participate as fully as possible in things she had said were important to her. The other three plans sampled were detailed, and showed that the service user had been consulted about their health and lifestyle. It was acknowledge these service users found undertaking this task more difficult. One service user had on file, documents which showed how they had been supported to get ready for their review meeting. This is a really positive piece of practice. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 11 Observation during the inspection, and from reading care files, it became evident that service users are supported to be as independent as possible. This includes taking responsibility for household tasks, meal and drink preparation, laundry, and shopping. One comment card received, reported in the persons opinion, the service user they visit had not been well consulted with about a move from one TRACS home to another, and that they felt this was undertaken without consultation. The morning and evening routines had been written in such a way that it promoted the service users independence. Meeting minutes and observation showed that the philosophy of doing with and not doing for is strongly promoted within the home. Risk assessments for two service users were assessed. In both cases the number and content of the plans was identified as needing further work. On service user tracked goes out of the home independently, and no plan to show the risks associated with this had been addressed were in place. One service user has been the subject of other service users aggression in the past, and no plan or assessment of the risk regards this was in place. The second service user tracked had risk assessments in place for manual handling and access to the kitchen. Risks associated with behaviour, and smoking were not available at the time of inspection, although TRACS later informed CSCI these were in place. The records of care were all stored securely, and protected service users confidentiality. Staff interactions with service users were really positive and respectful. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Service users are supported and encouraged to undertake a range of activities in the home, and in the community. Contact with family and friends are facilitated. The food provided is of a good quality, and to the service users satisfaction. Many of the dishes are home cooked. EVIDENCE: The opportunities offered and delivered to one of the service users tracked were considered to be very varied, and frequent. The inspector commented that the range of activities planned and undertaken were consistent with any person of the service users age and gender. It was positive to track the planning of activities from ideas raised at review meetings, into the care plan, onto the activity planner, and into the daily care notes. The other service users activities tracked showed that a number of opportunities to undertake both in house and community based activities had been offered but declined. The inspector recommended that this be reviewed to see if the service user needed support with motivation or low mood, if he Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 13 didn’t like the activities being offered, or if he was fully processing the opportunity being offered to him, and making an informed choice about whether or not to participate. During the inspection service users were supported to undertake in house activities such as a board game, word search, or household tasks, and some people were supported to go food shopping, to personal jobs such as banking, and undertaking laundry. The service users 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. The inspector did not track the planned menu or record of food eaten. The lunch served was freshly prepared and well presented. It was positive to see service users and staff sat together to eat and a nice atmosphere was created. Drinks and condiments were provided with the meal. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Personal care is planned and undertaken to a high standard. Service users are supported to dress in a style of their choice. Healthcare must be better planned to ensure that all needs are consistently met. Medication management must improve to ensure prescriptions and medication are checked prior to commencement of a new medication cycle, and that PRN protocols are available for all medications. EVIDENCE: The inspector met with all of the service users accommodated, and they had all been supported to undertake personal care. The morning routine was relaxed, and this had been undertaken at a time and in the way preferred by each individual. Staff had more consistently recorded the personal care offered and undertaken. In two of the plans sampled service users 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 service users accommodated have some additional healthcare needs. The plan of one service user with epilepsy was tracked. It has previously been required that this plan be further developed to contain information about the Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 15 usual type of seizure experienced, usual recovery, and the care and support required after a seizure. This had not been undertaken, and the plan continued to offer vague advice such as, “If the seizure is unusual in length or severity…” but no information provided against which to measure this. One service user had been prescribed medication for use in event of Angina. The plan of care made no mention of this, or the service users needs regarding this. Some of the service users accommodated can display difficult to manage behaviours. The entries made regards this in care notes were often vague, and included, “verbally aggressive to staff”, and “vocal and aggressive to others”. These statements had not been followed up with any further documentation. It was identified this area requires improvement; as such records provide the basis upon which to evaluate the effectiveness of relevant care plans and reactive management strategies. One service user is thought to experience pain. Medication to manage this had been prescribed, but no pain management plan was available, and this had not been robustly planned for in PRN protocols. The other medical details sheets showed that healthcare appointments had been offered and attended, but records relating to 2005 had been archived, and it was not possible to establish when periodic appointments had last been attended. It was recommended this be included in the relevant part of the care plan to ensure appointment are offered and planned at the required intervals. One comment card received reported that their experience of Evergreen staff was that they were, “very professional” and made, “every effort to identify the clients needs, spending quality time with him.” Medication management was assessed. Copies of the current prescription were available, and in all but one case this matched medication dispensed by the chemist. This was identified as potentially serious, as the checking of prescriptions by the staff prior to them going to the chemist, and upon receipt of the medication at the home had failed to identify this. This must be reviewed to ensure a robust system is in place. The as required (PRN) protocols were all identified as being overdue for review. Some PRN medication available was not listed on the MAR chart. Some PRN medication available did not have a protocol to underpin its use. The day of inspection was the first day of this medication cycle, and the MAR had been completed for all administrations, and signed to say medication had been checked into the home. It has been required the length of time open bottles of pills and medicine can be retained for be reviewed, as some open bottles had been dispensed over six months previously. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 16 Ageing, illness and death was not tracked at this inspection, but one comment card received reported that Evergreen provided, “Excellent care, enabling the client to die in his preferred place.” The professional was very complimentary about all aspects of the palliative care given to this service user, from staff at the home. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 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 home has an open culture and welcomes ideas and concerns from service users, and stakeholders. Adult protection concerns are identified, and the appropriate people notified. The manager must ensure work to ensure service users safety is undertaken. EVIDENCE: Comments made by service users in person, and in the comment cards reported that they do feel listened too, and feel that their concerns are taken seriously. The home has received one complaint since the last inspection. Records showed this had been taken seriously, and action taken to address the concerns raised. The inspector tracked work undertaken with one service user who had previously been subject to attacks by other service users accommodated. It was not evident that risk assessments or strategies to address the known vulnerability of the person had been developed. Potential adult protection issues had been identified by the manager, and during the inspection it was apparent that these had been taken seriously, and the incidents reported to all the relevant people. The inspector identified one service user could be vulnerable when accessing the community without staff support. It was required this area be explored and underpinned with a risk assessment. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 TRACS is working hard to improve the accommodation at Evergreen. Service users 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 inspection work to develop and improve upon the premises were underway. The work scheduled includes the improvement of three ground floor bedrooms, the addition of three ensuites to first floor bedrooms, a new WC, new laundry and a re-located assisted bathroom with additional shower. The work being undertaken was clearly intrusive to the normal operation of the home, but it was evident ways to minimise this had been explored. The inspector required that risk assessments regards the ongoing work, and impact on other risks such as fire and infection control need to be more regularly reviewed, to reflect the current work being undertaken. When completed the home will require re-decoration throughout. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 19 The kitchen is not being altered structurally, but the cupboards, shelves and doors were all observed to be very worn, and it is required replacement of this be scheduled in the medium term. The plans submitted include the development of a laundry in a stand-alone building, external to the main home premises. The CSCI would find such a plan unsatisfactory, and the effect on service users independence and staff allocation would be negative. CSCI are consulting with TRACS on an acceptable solution to this problem. The home was as clean as could be expected considering the level of work being undertaken. One service user utilises a commode. The plan for hygienic cleaning of this could not be followed due to the building work, and absence of the laundry sink. It is required this be urgently reviewed. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 36 Service users are supported by staff they know and like. Positive interactions between service users and staff were evident throughout the inspection. The manager must evidence that all recruitment checks are undertaken, prior to a new starter commencing work in the home. EVIDENCE: The comments made by service users about staff, both in person and in the comment cards were entirely positive. The interactions between staff and service users were observed to be very friendly, and reassuring. The number of staff on duty at the time of inspection was ample to enable service users to access the community, and to receive the level of support and supervision required. The inspector raised concerns regards staff levels at weekends, when there are sometimes three staff on duty all working a long day. The staff are entitled to a one-hour break, which would result in the number of staff available dropping to two, for three hours during the day. While the inspector acknowledges the reduced number of service users accommodated, she did express concern that this would be adequate to ensure service users are supervised, and supported as required, and that staff are also able to fulfil their wider multi-role responsibilities. It is required this situation be reviewed. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 21 The recruitment records for three staff were assessed. One application form did not evidence the full previous work history, or account for gaps in employment. This person had not supplied a passport, or evidence provided one was not available. In another file no identification was available. The third file was complete. The previously made requirement regards training was not assessed. The inspector was pleased to meet a new member of staff on induction. It was evident he was receiving a structured start to the home and the organisation. One file was tracked regards the support offered to staff in formal supervision. This had been undertaken regularly and was very detailed. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 The management of Evergreen is service user focussed. Routine servicing and inspection of appliances and equipment protect Service users, staff and visitors’ safety and welfare. EVIDENCE: The manager at Evergreen is very service user focussed, and endeavours to provide a well run home. The inspector got a strong sense of “team” among the staff. The inspector met two members of TRACS management team. One undertaking the regulation 26 visit, and the other undertaking a quality audit. A poster in the home, and discussion with service users confirmed that their views are sought by the organisation, and included in future service development. In house checks of the fire alarm, emergency lighting and hot water delivery temperatures had been undertaken. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 23 Evidence that the fire, electrical, gas and lifting equipment had been serviced as required were also available. Fire drills have been undertaken as required, but it is recommended that the procedure for evacuating the home at night be practised with staff and service users. Staff have commenced three monthly health and safety checks of the premises, which is positive. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 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 1 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 1 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 X 3 3 3 X X 2 X Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA3 Regulation 23(1)(a)(2)(a) Requirement Work in hand at time of inspection. The environment must be further developed to meet the needs of service users accommodated and the categories of registration. Risk assessments, which are fully reflective of service users needs, risks they take and are exposed to, must be developed. Outstanding from the previous inspection. The Epilepsy care plan must be reviewed in light of developments in this field. All health care needs must be planned for to include angina, and pain management. Requirement partly met. Weight monitoring must be undertaken consistently and records of such maintained. Monitoring of difficult to manage behaviour must be undertaken to enable effective evaluation and review of care practice and Timescale for action 01/06/06 2. YA9 13(4)(a-c) 01/05/06 3. YA18 12(1)(a) 13(4)(b) 01/05/06 4. YA19 12(1)(a) 01/05/06 5. YA19 12(1)(a-b) 01/05/06 6. YA19 12(1)(a) 01/05/06 Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 26 care documents. 7. 8. YA20 YA20 13(2) 13(2) Staff must ensure medication prescribed and received is correct. Open bottles of clear liquid medication must be discarded after 6 months, and bottles of medication with particles discarded after 3 months. Open bottles of tablets must be discarded after 3 months. Protocols for all as required medicines must be provided. All as required medication must be listed on the MAR. The provider must ensure all possible action to keep service users safe from harm is implemented. Work in hand at time of inspection. The premises must be audited and a plan of redecoration developed. This must include, flooring and décor. Plans detailing how the kitchen will be updated/replaced must be developed and forwarded. Plans for the upgrading of the kitchen units, and worktops must be scheduled, and undertaken. The building risk assessment must be kept under regular review to address the current risks posed by each phase of work. Work in hand at time of inspection. The available space in three of the service users bedrooms must be increased. Locks on service users doors DS0000016727.V285037.R01.S.doc 01/04/06 01/04/06 9. YA20 13(2) 01/04/06 10. YA23 13(6) 01/04/06 11. YA24 23(2)(b, d) 01/06/06 12. YA24 23(2)(b) 01/12/06 13. YA24YA42 13(4)(b-c) 01/04/06 14. YA25 23(2)(a) 01/06/06 15. YA26 12(4)(a) 01/06/06 Page 27 Evergreen Version 5.1 16. YA30 13(3) 17. YA30 13(3) 18. YA33 18(1)(a) 13(4)(b-c) 17(2) Sch 4 19. YA34 20 YA34 13(6) 21. YA35 18(1)(a) 18(1)(c) 1 must be reviewed, to ensure service users welfare and freedom of movement is maintained. A laundry that meets the needs of service users accommodated, and complies with fire, environmental, and building regulations must be provided. Facilities for hygienic cleansing of commode pans must be provided, and the risk assessment/protocol re this reviewed to reflect changes in the premises. It is required staff cover be reviewed and risk assessed when two staff are provided on duty. Outstanding from the previous inspection. Staff files must contain all documents as listed in schedule 4 of the care homes regulations. Evidence that gaps in employment history have been explored must be provided. Not assessed at this inspection. Training and updates must be provided to all staff at the required intervals. 01/05/06 01/04/06 01/04/06 01/04/06 01/04/06 31/12/05 Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 28 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 YA19 YA42 Good Practice Recommendations It is recommended the reason service users decline activities be explored. It is recommended that the last date health appointments were undertaken be recorded in care plans, to facilitate future planning. 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. Evergreen DS0000016727.V285037.R01.S.doc Version 5.1 Page 29 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. 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