Inspection on 27/06/07 for Evergreen

This inspection was carried out on 27th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Evergreen 10/05/06

Evergreen 09/12/05

Evergreen 23/06/05

Evergreen 14/12/04

Evergreen 05/08/04

Evergreen 05/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Evergreen 2 Brandreth Road Mannamead Plymouth Devon PL3 5HQ Lead Inspector Jane Gurnell Unannounced Inspection 27th June 2007 09:15 X10015.doc Version 1.40 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 DS0000003477.V334299.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Address 2 Brandreth Road Mannamead Plymouth Devon PL3 5HQ 01752 665042 NO FAX 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) Mrs Jacqueline Denise Tope Mr Roy Richard Tope Mrs Jacqueline Denise Tope Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 60 Date of last inspection 10th October 2006 Brief Description of the Service: Evergreen is situated within walking distance of Mutley Plain shopping precinct in Plymouth. The establishment is formed from two terraced Victorian villas that have been internally combined. The home has a family atmosphere due to the efforts of the owners and the staff, and because the home can only accommodate sixteen residents at any one time this ensures a non-institutional atmosphere. The home has the category of OP (older person) and has neither of the specialist categories for the provision of dementia care or severe physical disability. Evergreen does not provide nursing care. The home specialises in creating a homely environment to meet the individual needs of each resident. Accommodation is provided on both the ground and first floors. The home offers a large lounge room that has 2 seating areas, a dining room and a large conservatory area that leads to a small garden. Currently the fees range from £278.46 to £378 a week. Items not included in the fees include chiropody treatment, hairdressing, newspapers and magazines and toiletries. Information regarding the services provided at Evergreen can be obtained directly from the home. Evergreen DS0000003477.V334299.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 undertaken on 27th June 2007. The care staff assisted the inspector throughout the inspection and as the owners weren’t present at the time of the visit a return visit was made on 28th June to examine staff files and reviews the owners’ quality assurance processes. Prior to the inspection the Commission had sent surveys to relatives to allow them to comment anonymously and directly to the Commission with their views and experiences of Evergreen. All those returned praised the home and the care and support provided. The inspector spoke to each resident and the staff on duty and made a tour of the building. The care plans for 3 people were examined as well as 2 staff files, including one for a newly appointed member of staff. Records relating to the owners quality assurances process and the day-to-day running of the home were also looked at. What the service does well: What has improved since the last inspection? The radiators had been covered to prevent the risk of burns should someone come into contact with them when on. Both stair lifts had been replaced and 2 new bath chairs purchased ensuring the equipment provided is in good working order and meets the needs of those living in the home. Staff had undertaken a certificated course at a local college relating to the safe administration of medicines. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 6 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 DS0000003477.V334299.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough and comprehensive systems for admission allow people considering moving to Evergreen and their relatives to be confident that their needs can be met. EVIDENCE: Evergreen is a small home and as such vacancies become available infrequently. However the inspector had the opportunity to speak with someone who had moved in recently and she described her visit to the home before making a decision to move in. She said that she had been made very welcome and that her family had been given information about the services provided. A further information pack was available to new people to orientate them to the local area and life at Evergreen. Another person relatively new to the home said “I knew this was home as soon as I walked through the door”. Pre-admission assessments by both the owners and social services were evident in the care plans and ensured the care staff were aware of each persons’ health and social care needs prior to their admission. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of those living at Evergreen were being met and people were treated respectfully. Medication administration practices were safe. EVIDENCE: The inspector spoke to each of the people living in the home and all commented very favourably about the care and support they receive. The home was described as “lovely” and “excellent”; one person said “you couldn’t find a better home”, another “this is my second home, I can’t express how happy I am here”. Both those living in the home and their relatives said how very much they valued the family atmosphere with Mr and Mrs Tope and their daughter, owning and managing the home. Comments from relatives included “because the home is reasonably small they give more personal attention”; “the overall care is very good. Staff are knowledgeable, helpful and always friendly and patient” and “excellent family, caring atmosphere”. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 10 The care plans for 3 people were examined in detail. These described each person’s care needs and the action required by them to meet these in a consistent manner and to allow monitoring for changes in health and well being. All 3 care plans included risk assessments relating to activities of daily living, mobility, falls and skin care with the aim for protecting each person from the risk of injury. The owners said the care plans were reviewed each month and updated as necessary to reflect current needs. This review was evident in the care notes for 2 of the 3 care plans examined. People are encouraged to retain responsibility for their own medication should they wish to do so. A small safe was provided for each person for valuables and this can be used for medicines if necessary. Medication was stored in a locked cupboard under the stairs and the records of administration were neat and accurate. There were no controlled drugs at the care home however an additional lockable tin was available should it be necessary. Care staff confirmed that they had completed a distance-learning course with a local college regarding the safe handling and administration of medication to support their knowledge and safe practice. People with terminal illnesses may remain at the home if the care staff, supported by the District Nursing Service, can continue to meet their needs. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to maintain their independence and chosen lifestyle. Meals are plentiful, varied and nutritious. EVIDENCE: People described that they are encouraged to come and go freely from the home and to maintain contact with family and friends. Leisure and social activities organised by external facilitators were planned several times a month: a list was provided on the notice board and the people said these were much enjoyed. The care home maintains links with the local primary school, and at certain times during the year, for example at Christmas, invite the children to attend the home to celebrate with those living there. Care staff facilitate spontaneous activities according to peoples’ wishes and the weather, such as daily walks, visits to the local shops and other places of interest. Relatives and friends are welcome at the home at all reasonable times. Further comments from relatives included “the staff are friendly, happy people and go out of their way to make the residents laugh which I feel is Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 12 important”, and the home “provides a homely atmosphere where residents are not obliged to lead an institutional lifestyle if they don’t wish. Mum values her privacy and this is respected” The meals were described as “excellent” and “very good”. People said meals were plentiful with fresh fruit and vegetables and that there was always a choice. Breakfast in bed was provided each day. A recent quality audit by the owners to ascertain peoples’ views of the quality of the services, including the meals, indicated that people were very satisfied with the menus and the choice of food available. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and suggestions from those living at Evergreen, their relatives and other visitors to the home, were treated seriously. People were listened to and issues resolved promptly. EVIDENCE: The owners and staff were described as very approachable by both those living in the home and their relatives. There was confidence that any issues of concern would be listened to and dealt with. Neither the home nor the Commission had received any complaints about Evergreen since the last inspection. A copy of the complaints procedure was available on the notice board in the hallway and was detailed in the home’s Statement of Purpose and Service User Guide. The information pack provided a statement of peoples’ rights and information about advocacy services. Staff had received training in issues relating to abuse and the protection of vulnerable adults and were aware of their responsibilities should an issue of abuse be suspected. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Evergreen provided a pleasant, well-maintained home that is comfortable and warm and which provided sufficient facilities to meet peoples’ needs. EVIDENCE: All communal rooms and bedrooms were pleasantly decorated and furnished, reflecting the period of the building. The home was found to be very clean and tidy and those spoken to said that it was always clean. A small safe is provided to each person to store their valuables and the owners described their plans to fit bedroom door locks to provide both privacy and security: evidence was provided that a contractor had been contacted to undertake this work. Radiators have been covered to prevent the risk of burn injuries should someone come into contact with them when on. At previous inspections the Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 15 owners confirmed that hot water control valves have been fitted to baths to protect from the risk of scalds: the water was checked by the inspector and found to be of an acceptable temperature indicating that this was the case. A maintenance programme for the forthcoming year provided details of the plans to refurbish and upgrade the environment as funding allows. These plans included the necessary upgrading of the laundry room to ensure that it is easily cleanable, reducing the risk of cross infection as it is currently being is used as a store room for the freezer. Also included were new carpets to the communal areas and hallways, refurbishing the conservatory, upgrading the ground floor bathroom and making the access to the garden level. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well-trained and motivated and employed in sufficient numbers to meet the needs of those currently living in the home. Recruitment practices protect vulnerable people. EVIDENCE: All those people spoken to praised the staff and described them as “excellent” and “really nice and friendly”, with nothing being too much trouble. They said they received assistance promptly indicating that there were sufficient staff employed. One relative described the staff as “courteous, polite and approachable”. At the time of the inspection there were 14 residents living at Evergreen. There were 4 care staff on duty and staff confirmed that this is usual. Three care staff were available during the evenings and one waking and one sleep-in member of staff at night. These numbers do not include the owners and their daughter who work in the home 5 days a week including at weekends. The owners also provided sleep-in cover. Both care staff and those people spoken to felt that there were sufficient care staff available. Domestic staff were employed each weekday morning. Many of the care staff have worked at Evergreen for a considerable period of time and as such are very experienced. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 17 Care staff confirmed, and records supported, that they have undertaken training in manual handling, first aid, fire safety and food hygiene. In addition to this the majority of care staff have completed NVQ training to either level 2 or 3, a recognised national training course for which staff have had to demonstrate their knowledge and skills in caring for older people. Those care staff files examined provided evidence that the necessary preemployment documentation had been obtained including 2 written references and a Criminal Record Bureau Disclosure, ensuring as far as possible only suitable staff are employed. Newly employed staff were provided with induction training relating to care principles and values and the needs of older people and work under supervision until they are familiar with peoples’\needs and deemed competent by the owners. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Evergreen is a well managed home. The owners and their staff team strive to provide a homely, stimulating and safe environment that respects and protects residents’ rights. EVIDENCE: People said they feel safe and secure in their home and that the home was very well managed. They said the approach of the mowers and their commitment makes Evergreen an extremely pleasant home to live in. Mr and Mrs Tope are available most days, including weekends and were described as very approachable and easy to talk to. Their frequent attendance ensures consistency in care and good relationships are maintained not only with those living in the home but also with relatives and other health care professionals, such as social workers and GPs. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 19 Staff confirmed that they meet with the owners regularly to ensure that peoples’ needs continue to be met and any issues dealt with promptly. Records confirmed that staff receive supervision to review their work performance and training and development needs. Both Mrs Tope and her have NVQ 4 in Care and the Registered Manager’s Award indicating that they have successfully demonstrated their knowledge in the care and management issues of owning and running a care service. The owners provide safekeeping for money for 3 residents: individual records were maintained and receipts kept for all expenditure enabling this money to be easily audited. A record of the owners’ consultation with people living in the home as well as their relatives was available from Jan of this year and detailed views about the service and support provided by the home: comments were very favourable. Further in-depth consultation is undertaken from time to time with regard to specific issues such as menu planning and meal choices; the time of getting up and going to bed; involvement in hobbies and leisure activities. Summaries of these results were compiled and provided to people to allow them to comment and make suggestions for improvement. Surveys were also sent to care staff as part of the quality assurance process and staff meetings are held periodically to discuss relevant issues. Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 3 3 3 Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Evergreen DS0000003477.V334299.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 DS0000003477.V334299.R01.S.doc Version 5.2 Page 23 - 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!