Inspection on 29/05/07 for Evergreen

This inspection was carried out on 29th May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 26/07/06

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 Key Unannounced Inspection 30th May 2007 09:30 Evergreen DS0000016727.V336766.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.V336766.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.V336766.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 evergreen@tracscare.co.uk suehullin@tracscare.co.uk Tracscare Group Ltd 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 Vicki Mae Morris Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Evergreen DS0000016727.V336766.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. 26/07/06 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. On the first floor are a further four single bedrooms, another bathroom, wc, and staff sleep in room. 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 up to 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. Previous CSCI reports are available to read at the home on request from staff. Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one full day by one inspector. This was the homes key inspection for the inspection year 2007 to 2008. The Manager was on annual leave at the time of the inspection visit. The Inspector met all seven people living at the home. Time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. One Health professional who was visiting the home was spoken with. Prior to the inspection an Annual Quality Assurance Assessment was returned to the Commission which gave additional information about the home. Five people living at the Home returned a survey to CSCI known as “Have your say about…” it was recorded that staff had assisted three people to complete the survey. All information looked at was used to determine whether peoples varied needs are being effectively met. 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. People are supported by staff they know, and who are familiar with their needs. There is enough staff employed so that the people living in the home can be supported to do the things they want to do. 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. Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 6 Staff ask people what they think about the home and if anything can be done to make their lives better. 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. Some staff need refresher training in physical intervention so they and the people living there can be safe if someone is behaving in a way that they or others can get hurt. The emergency lighting must be tested monthly to ensure it is working and people are not put at risk in the event of a fire. Records of food provided should be more detailed so that staff can effectively monitor that individuals are having a healthy balanced diet. Review of the induction arrangements for bank and agency staff is needed to ensure they are fully aware of the homes emergency procedures. Evergreen DS0000016727.V336766.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. The summary of this inspection report can be made available in other formats on request. Evergreen DS0000016727.V336766.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.V336766.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. 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. People are given have the information they need to ensure they can make a choice about whether or not they want to live at the home. An assessment is undertaken prior to moving in, to ensure the home is able to meet the needs of the individual. EVIDENCE: The Manager has produced a Statement of Purpose and Service Users guide. These have previously been observed to be both informative, and written in an accessible format. One new person has been admitted to the home. The Deputy Manager said that they had been provided with a copy of the Service Users Guide and a welcome pack that included new towels and toiletries. The individual confirmed they had received the ‘welcome booklet’. The work undertaken to assess one individual prior to admission to the home was tracked. An Initial assessment had been completed in consultation with a social worker, nursing staff, the individual and their spouse. The assessment covered all areas of need and any possible risks had been assessed. The Manager had completed a feedback form in response to the assessment confirming the individual’s needs could be met at Evergreen. People are offered the opportunity to visit the home before moving in. Discussion with staff and records shows the individual who had recently moved Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 10 in had an initial visit, then came for Sunday lunch then had an overnight stay. The individual confirmed staff had showed them round the home before they moved in. It is good that a record of the visits are kept that includes interaction with other people who live at the home and their feedback. Two files were sampled to check that people living at the home had a copy of their terms and conditions. One person who had been at the home some time had a signed agreement in place. For one person who had been at the home a short an agreement was in their file but it had not been signed by them or their representative. This needs to be done to ensure they are fully aware of the terms and conditions of their stay. Evergreen DS0000016727.V336766.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have detailed information in care plans as to how support each person. People are supported to make decisions about their lives and are supported to take risks within a risk assessment framework ensuring they are safe. EVIDENCE: Care plans for two people who live at the home were sampled. 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 a six monthly review is held with each resident, people important to them are invited to attend. Objectives are agreed at the review. For one person this included staff to wear name badges as the individual forgets their names. Staff were observed wearing badges during the visit, this showed that objectives are acted on. One person shouted during the visit and sounded very angry. Staff went to speak with him. They were heard to remain calm, found out what the problem was and reassured the person in line with their care plan guidelines. Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 12 Choice was observed to be offered to people throughout the visit. People have their own notice board to inform them of what is happening, activities or educational information. An easy read version of the new Mental Capacity Act had been made available along with the complaints procedure. Minutes of meetings for people who live in the home were on display. Meetings are regular. Topics discussed include where people would like to go on holiday, activities, food, the environment and things they like and don’t like about the home. A Focus day is also held annually for people who live in Tracs homes. Records included individual risk assessments for each person. These stated how staff are to support each person to reduce the risks of there being a fire, when accessing the community, vehicles, undertaking household activities, people’s vulnerability, money handling skills and manual handling. All risk assessments had been regularly reviewed and updated where necessary where there had been changes in the person’s needs or their behaviour. Evergreen DS0000016727.V336766.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home experience a meaningful lifestyle. EVIDENCE: Sampled records and discussions with staff and people who live at the home show that a variety of activities are on offer consistent with any person of the same age, culture and gender. For the new person admitted to the home their care plan records how interests in activities will be maintained, for example their interest in Birmingham City Football Club. Activity charts show that activities on offer include independence skills, contact with family, shopping, walks, buying newspapers, library, church and cinema. It is good that staff are supporting the new person to continue to use a hairdresser they have visited in the past to maintain links with the community where they used to live. During the visit people were observed being supported by staff to play dominoes and snakes and ladders, they were all enjoying the game. Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 14 Discussion with staff shows theme nights are held at the home so that people can experience the foods and activities of different cultures. Previous themes have included St Patrick’s day and an African night, a Chinese night was arranged for a few days time. Holidays have been arranged for those who want to go whilst some individuals have chosen day trips instead. It is an improvement that records now have a space for staff to record if the person enjoyed the activity or declined to take part. This helps staff plan with individuals what activities they would like to continue doing. People’s rights are respected, staff were observed to offer choice through out the visit. Where people had chosen to lie in bed and not get up until later in the day this right had been respected. The care plan shows agreement obtained from one individual regarding the use of a peep hole at their bedroom door. This is because the person has epilepsy and needs checking on at night but does not want staff disturbing him by opening the door. People living at the home 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. Care plans record a full list of birthdays of family so that staff can support people to send out cards. One relative spoken with said there were no unessecary restrictions on visiting times and said they can stay and have a meal at the home if they want to. Staff said they were in the process of updating the menu so that it was appropriate for the summer. Minutes of people’s meetings show that they have recently been consulted on the foods they would like on the new summer menu. One person who lives at the home said he was going out later that day with staff support to do some food shopping. He said he likes to do his own shopping and to cook his own meals. Fresh fruit was observed to be available in the kitchen. One person who lived at the home commented that ‘the food at the home is good’. The current menu in place shows culturally appropriate and varied meals on offer, but does not record puddings or sweets. The Deputy Manager said staff try to offer healthy sweets such as fruit or yogurt. Food eaten is recorded in daily records but some records needed improvement so that staff can establish if each person is having a healthy diet as the detail of recording does not always show five portions of the recommended fruit and vegetables per day. Evergreen DS0000016727.V336766.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal support in the way they prefer and require and their health needs are well met. The management of the medication generally protects people and ensures their well-being. EVIDENCE: Care plans contain detailed information about individual personal care needs so that staff know how people like to be supported. People living in the home were dressed appropriately to their age, gender, the weather and the activities they were doing. The staff team is mostly female but more males than females live at the home so gender composition of staff does not reflect people they support and so consideration should be given to increasing the number of male staff at the home. Records showed that the people living in the home had their medication regularly reviewed and they had regular health check ups. Where appropriate the advice of health professionals is sought. One person is having regular input from the physiotherapist to assist in him walking with an aid. One person has been unwell and records and discussion with staff shows that advice had been Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 16 sought from the GP. Discussion with one health professional who was visiting the home indicated they had no concerns about the home. Medication systems are generally satisfactory. Storage of medication is in a locked cabinet. A weekly check of medication is done to ensure the cupboard is clean and medication is within its use by date. Copies of prescriptions are retained so that staff can check the correct medication has been received from the chemist. Medication administration records were sampled and a few gaps were observed. The records must be signed after administration to show people have been given the medication they need. Where individuals are prescribed PRN (As required) medication a protocol is in place stating when, why and how this should be given. Stock checks of medication are completed, generally weekly. These showed two incidents where some paracetamol tablets had gone missing. Procedures have been reviewed for administration and the home is changing to a different pharmacy where medication will be dispensed in a blister pack reducing the likelihood of future occurrences. For one individual who was ill and has now sadly passed away the home had district nurse support on a near daily basis and support from a visiting hospice service. The Deputy Manager said that staff and people living at the home had been given a contact number of a bereavement counsellor. People living at the home were offered the opportunity to go to the funeral but chose not to attend. Evergreen DS0000016727.V336766.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home know how to make a complaint and that their views will be listened to and acted on. Arrangements are sufficient to ensure that people are protected from abuse, neglect and self-harm. EVIDENCE: Profile sheet in people’s files records they have received a copy of the complaints procedure, it is also on display in the home. Surveys received record a few people who live at the home were still unaware of the complaints procedure but staff have explained the procedure to them again. The CSCI has not received any complaints regarding this home since the last inspection. The home’s own complaints log records one recent complaint. This was from someone who lives at the home who was unhappy about the behaviour of someone else who lived at the home. The Manager apologised for the incident and a record has been made of follow up action. The Complainant was happy with the outcome. One person spoken with said he has no complaints but would speak to the Manager if he had to complain. A relative spoken with said that any concerns raised are always acted on and they would have no hesitation in making a complaint to the Manager. Since the last inspection there has been an adult protection issue between two people who live at the home. This was reported appropriately to social services and the CSCI and action was taken to protect people. All staff at the home have received training in protection of vulnerable adults. It was suggested at the last inspection that the duration of this training should be increased. The Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 18 Annual Quality Assurance Assessment completed by the Manager records this is to be reviewed this year. Care plans sampled includes behaviour management strategies that included triggers for behaviour, distraction techniques and the use of studio III (a form of physical intervention). Staff spoken with had good understanding about the use of Studio III and that it is used only as a last resort. Both described using other techniques to calm the situation before using physical intervention. A money handling assessment is completed for each person to see what support they need from staff. Monies are checked daily by staff. The finance records for two people were sampled. Receipts were available for expenditure. It is good that the area manager checks monies as part of her visits to the home to check they are correct. Evergreen DS0000016727.V336766.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, safe and clean environment that generally meets their individual needs EVIDENCE: Evergreen is an adapted domestic property, and from the outside is not distinguishable as a care home. Hallway carpets were observed to be quite stained but were already scheduled to be cleaned later that day. A contractor arrived during the visit to clean carpets. The lounge carpet and décor was worn but this has been identified by the Manager and these are to replaced and redecorated in this years budget. The conservatory is used as a smoking room and an extractor fan is fitted to help remove the smoke. Reports show the type of door to the room is under review to see if an alternative door would keep the smoke out of the lounge more effectively. Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 20 People at the home have their own bedroom. One person showed me their room and said it was ‘nice’ and that they had everything they needed. They had not lived at the home long but the room was already very personalised with personal possessions and reflected age, gender and culture. New flooring has been installed in the laundry as previously required. The kitchen has been refurbished to include new units, worktops, tiles and floor. One worktop is at a lower level for use by a wheel chair user if needed. The Deputy Manager said that a quote was obtained the week before for work to add en- suite bathroom to the ground floor vacant bedroom to relieve the pressure on the use of the ground floor bathroom. Staff said that two people cannot use the bath at the moment as they had recently both nearly slipped so needed a new bath that meets their needs. The Deputy Manager said they would be getting a new bath that is suitable and an Occupational Therapist is visiting in a few weeks and the bath will discussed. Satisfactory infection control procedures are in place. The laundry is sited away from the kitchen and dining room. Hand washing facilities are available with liquid soap and paper towels. The home observed to be clean. One relative spoken with said the home was always clean. A recent Environmental Health Officer report said there were generally very good standards of hygiene in the home but they recommended installation of fly screens in the kitchen, an invoice at the home evidences there are on order. Evergreen DS0000016727.V336766.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home benefit from a generally well trained and supported staff team that can support them to meet their individual needs and achieve their goals. People are protected by the home’s recruitment practices. EVIDENCE: One relative spoken with said that staff are ‘excellent’. Support to people was observed to be given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Staff spoken with showed a good understanding of the needs of the people who lived at the home. Nine of the fifteen staff have completed an NVQ in care some at level 3, so ensuring that staff have the skills and knowledge to meet individual’s needs. The number of staff on duty at the time of inspection was satisfactory to enable people to access the community, and to receive the level of support and supervision required. The staff rota for April and May was observed and showed that generally four staff are on duty during the day. Staff spoken with felt that staffing levels in the home were appropriate to meet the needs of the people who lived there. Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 22 Recruitment records for two new staff were sampled. These showed a robust procedure had been followed. These included a photograph of the person, the required recruitment records and evidence that a Criminal Records Bureau (CRB) check had been undertaken so that suitable people are working there. The Provider has dismissed two staff regarding inconsistencies with their work visas. This had resulted in some staff vacancies. Four new staff were recruited in March and the Deputy Manager said the home is now fully staffed, although one staff has since handed in their notice. New staff had an initial induction off site, then during their first week worked as extra to staff. An Induction booklet is worked on for first 12 weeks of employment, this links to LDAF standards. Anti discrimatory training is provided at induction and the Annual Quality Assurance Assessment (AQAA) identifies that a diversity training package is being developed. The home has achieved the ‘Investors in People’ Award. Two staff spoken with confirmed they had done all their mandatory training. One said she had found the training on cancer from the hospice service very useful in meeting the needs of one person who has since died. Staff have done manual handling training as previously required. Three new staff are booked to attend Studio III training in June, one has already done it. Four existing staff are overdue studio III refresher and this will need to be booked as a date had not been set. Staff have done first aid and food hygiene. Staff had fire training in May, and it was scheduled again for September. However the arrangements for ensuring bank or agency staff are trained in the homes fire procedures needs review as a recent fire drill showed that a bank staff was unsure what to do when the alarms sounded. Staff meeting minutes show meetings are regular. Areas discussed include care plans, risk assessments, church services, complaints procedure, holidays. Files of new staff sampled show both had formal supervision within 1 month of starting work at the home so that they know how to support the people living in the home and their training and development needs are identified. A wall planner shows a schedule of regular staff supervisions. Staff spoken with confirmed supervision is regular. Evergreen DS0000016727.V336766.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager communicates a clear sense of direction so that individual’s needs are well met. The views of people who live at the home underpin all selfmonitoring, review and development of the home. Peoples health and safety is generally promoted and protected. EVIDENCE: The manager at Evergreen is very person focussed, and endeavours to provide a well run home. The Manager is registered with the CSCI and has the experience and qualifications needed to manage the home. Systems to ensure quality are in place, these include the views of people who live at the home, staff and others. Monthly visits to the home are made 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’. A Quality Assurance audit was done in May 07. In February an audit of care Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 24 plans was done and some areas for improvement were identified. Where improvements needed are identified a ‘corrective action plan’ is formulated. In house checks of the fire alarm, emergency lighting and hot water delivery temperatures had been undertaken. Unfortunately, since Christmas the emergency lighting had been tested six monthly instead of monthly as it had previously been done. A telephone discussion with the Manager after the inspection indicates that a different member of staff had taken over the testing and in error had not realised that tests must be monthly. The Manager said this would be rectified. Evidence that the fire, electrical, gas and lifting equipment had been serviced as required were was available. Staff test the fridge and freezer temperatures daily and records showed that these were within the limits for safe food storage. A Fire drill was done in May and then again a short while later as a new person had moved in and needed to be made aware of the fire procedure. It is good that a record is kept of fire instruction to people who live in the home and the fire procedure is on display in an easy read version. A Health and Safety audit was done in May, this was generally satisfactory but it did not identify the deficit regarding emergency light testing and ensuring bank / agency staff are aware of fire procedures as identified in the Staffing standards of this report. Evergreen DS0000016727.V336766.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 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 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 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X X 2 X Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes, number 1. 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 YA20 Regulation 13(2) Requirement Timescale for action 30/07/07 2. YA35 18(1)(a) 3. YA42 23(4)(c) Medication administration records must be signed when medication has been administered to ensure people are receiving the medication they need. Previous requirement date 15/09/06. Ensure staff receive 12 30/08/07 monthly refresher training on the use of studio III (physical intervention) so that staff know how to use it safely without putting people at risk of harm. The emergency lighting must 30/07/07 be tested monthly to ensure it is working and people are not put at risk in the event of a fire. Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations People should be given a copy of the terms and conditions of their stay before they move in to the home. These should be signed by the resident or their representative to ensure they are fully aware of the terms and conditions of their stay. Records of food provided should be more detailed so that staff can effectively monitor that individuals are having a healthy balanced diet. Work to add an en-suite bathroom on the ground floor should commence as soon as possible to relieve the pressure on the use of the bathroom. Assessment of the needs of individuals regarding access to a bath should be done without delay so that people can have a choice of a bath or shower. Review of the induction arrangements for bank and agency staff is needed to ensure they are fully aware of the homes emergency procedures. 2. 3. 4. 5. YA17 YA27 YA27 YA35 Evergreen DS0000016727.V336766.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Regional Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 DS0000016727.V336766.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. 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