Inspection on 30/12/05 for Evergreen

This inspection was carried out on 30th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 24/05/07

Evergreen 25/05/06

Evergreen 15/06/05

Evergreen 18/11/04

Evergreen 05/05/04

Evergreen 06/01/04

Evergreen 12/03/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Evergreen 55 Barrow Road London SW16 5PE Lead Inspector Lynn Hampton Unannounced Inspection 09:00 30 December 2005 th DS0000022799.V263226.R01.S.doc Version 5.0 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 DS0000022799.V263226.R01.S.doc Version 5.0 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. DS0000022799.V263226.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Evergreen Address 55 Barrow Road London SW16 5PE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208-677-4273 Jane`s House Limited Mr Atmah Victor Barsati Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places DS0000022799.V263226.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Evergreen residential care home provides accommodation and support for up to three adults who have support needs due to enduring mental health difficulties. At the time of this inspection there were no vacancies. The service is located in a former private house, which is sited in a quiet residential street and is indistinguishable from other houses in the street. The home is situated close to shops and amenities and has good access to public transport. The registered manager owns the property and also owns two other small homes nearby. During the inspection it was evident that the home has been well maintained and offers a homely physical environment for service users. It is laid out over three floors. The ground floor has a staff office, kitchen/diner, and a large communal lounge area. To the rear of the home there is a large garden. The first floor has the service user bedrooms, a toilet, and a bathroom with shower facility and toilet. The upper floor has sleeping accommodation for staff. DS0000022799.V263226.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in the early part of a weekday morning, 30th December 2005, and lasted three hours. During the visit the inspector met the assistant manager, and one of the care staff. A range of documents was examined and a tour of the building took place. The inspector met and spent time with all three current residents, all of whom were articulate and able to express their views on the service provided at the home. What the service does well: What has improved since the last inspection? The staff and residents of the home remain stable, and no changes have been made to the home since the last inspection. DS0000022799.V263226.R01.S.doc Version 5.0 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. DS0000022799.V263226.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000022799.V263226.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this Unannounced inspection visit. Standards 1, 2, 3 and 5 were assessed at the last inspection visit (June 2005) and were found to be met. EVIDENCE: DS0000022799.V263226.R01.S.doc Version 5.0 Page 9 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 Routines in the home are user-led. Service users are regularly consulted about decisions that effect them, and are supported to lead as independent a lifestyle as possible. Case files are held at the home in respect of each service user, which reflect their changing needs, but these need to more clearly demonstrate the care planning process and support being offered, and include information about financial assessments and finances. EVIDENCE: There were a number of ways in which it was apparent that routines of the home were user-led, and that residents are able and are encouraged to make decisions about their lives. During the inspection, residents went out for walks or to activities, made telephone calls, and they confirmed to the inspector that they could come and go freely as they had keys to the front door. They are able to choose when to get up/go to bed, and reported that they are regularly consulted and involved in decision-making. DS0000022799.V263226.R01.S.doc Version 5.0 Page 10 Case files seen contained daily logs, monthly evaluations, care plans, minutes of review meetings and Care Programme Approach information, which indicated that residents’ needs are assessed and kept under review. Care plans and reviews were recent and up to date. Evaluations included information on physical health, mental state and activities. One multi-disciplinary care plan review seen contained specific reference to supporting the person to learn to manage her finances. This mentioned that the local authority was acting as Trustee, and that it was hoped to help her to manage her personal allowance (which was to be paid to the home) and open a Post Office account. There was no information in the file about what action had been taken by staff at the home to implement this. There was no financial assessment or information about her entitlement or how the Trusteeship affected her and her finances. A hardback book had been put in place, which contained a list of ‘pocket money’ paid to the resident by the home, which the resident signed. This would benefit from clarification of exactly how much she is entitled to, and have a running total of any unspent balance. This was discussed with the assistant manager, who was able to describe what action was being taken to familiarise the resident with handling money, which was hampered by her visual impairment (this could limit her ability to accurately identify coins and notes). Staff accompanied the resident to go shopping, to familiarise her with spending and purchasing personal items. The care planning process and records should support this work, and clearly identify aims, timescales, and how staff will work towards goals such as opening a savings account. See Requirements. DS0000022799.V263226.R01.S.doc Version 5.0 Page 11 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, 17 Service users have opportunities and support to enable them to maintain appropriate lifestyles both within and outside the home. Contact with friends and family is supported and encouraged. Service users are involved in choosing and preparing individual meals, which is good practice. EVIDENCE: Residents that the inspector spoke to confirmed that they were able to choose activities, and there was a range of evidence from these conversations and observations during the inspection that they have opportunities for personal development. Residents maintain contacts with friends and family - one resident told the inspector that since he had lived in the home, he had been able to make friends and get to know the local area. Another regularly attended church and had spent Christmas with friends that he had made there. Friends and relatives are able to visit the home, and the owners had arranged for a Christmas party to be held for all the residents of the three homes. DS0000022799.V263226.R01.S.doc Version 5.0 Page 12 Interaction between residents, and between staff and residents, was observed to be warm and friendly. There was a pleasant atmosphere at the home, with residents chatting and laughing together as they cooked in the kitchen. Routines around mealtimes were fully user-led, which is to be commended. Residents can use the kitchen to make meals and drinks when they choose. Support is given to prepare them for more independent living where appropriate. One resident told the inspector that he was considering move-on options and that staff offered him support to learn skills such as cooking when he felt ready to do so. That day, he told staff that he wanted to cook his own lunch, and the inspector saw that he was offered practical and helpful support in preparing this and using the oven. Another resident is an experienced cook and prepared lunch with minimal supervision from staff. She is supported to go shopping for cooking ingredients, including fresh meat, vegetables and fruit, which ensures that she had a range of meals to suit her personal and cultural preferences. Staff told the inspector about how they encouraged residents to make healthy eating options, including reduced salt intake. Staff do prepare lunch on a daily basis for any of the residents that want it, and residents said that they were offered choice and meals were “really good”. There was a well-stocked freezer in the dining area, which contained fresh meat as well as processed (such as beef burgers). There was also a cellar, which was well stocked with a range of dry foods, cans and packet food as well as vegetables. DS0000022799.V263226.R01.S.doc Version 5.0 Page 13 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 Service users receive personal support appropriate to their needs and wishes, and health care needs are comprehensively addressed. Service users are consulted about their final wishes, which promotes respect. Errors in medication recording were found, as had been identified at the time of the last inspection. These must be addressed as a matter of priority, and action taken if service users do not receive medication due. EVIDENCE: Residents spoke positively of the support that they received in the home, and felt that it had helped them make personal progress. They all said that they liked living in the home, and had no complaints or concerns. One gave the inspector examples of how he felt that being at the home had helped him, and he had ‘moved on’. One resident told the inspector that he would like to understand more about his illness and symptoms. Consideration should be given to contacting the ‘Hearing Voices’ Network, or other resources, which may be able to provide useful information or support to residents and staff. DS0000022799.V263226.R01.S.doc Version 5.0 Page 14 Case records indicated that issues relating to residents’ health are comprehensively addressed. This included information about general health checks, chiropody, opticians, gynaecological checks and investigations for specific conditions. Administration of medication was observed, and was of a good standard. A Requirement was made in the report of the last inspection, that the registered person must make sure that all medication received is recorded accurately at the time of receipt and a running total is kept on the medication sheet. A record book of medication received from the pharmacy is kept, and at the end of the month, a member of staff checks the balance of tablets and this is now recorded on the medication charts. This was checked and the balance did not correspond with stocks held. In one case, staff were confident that medication had been administered, which would indicate that the monthly check count had been inaccurate. In another case, it was identified that a resident may miss his medication if he goes out in the afternoon without letting staff know (who can then give him his medication to take with him). In these cases, staff should not sign to indicate medication as given. A zero or cross should be entered to indicate a missed dosage, which will enable staff to monitor the situation and take action to ensure that he is receiving adequate medication levels. This was discussed with the staff on duty, who demonstrated an awareness of the issues involved, and the assistant manager outlined steps that he would take to address the situation. See Requirements. Continuing non-compliance with the previous Requirement (regarding accurate records of medication) will lead to consideration being given to Enforcement Action. Consideration should be given to purchasing a medication triangle, which will help make tablet counts easier. Case files contained ‘Final Wishes’ documentation, which includes details of who the residents wish to be informed of their illness and death, and funeral arrangements. This is to be commended. DS0000022799.V263226.R01.S.doc Version 5.0 Page 15 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 Service users reported that they were listened to, and had no complaints. EVIDENCE: Residents told the inspector that they knew how to make a complaint; although one stressed that he did not have any complaints at all about the service, saying that they had “done so much for me”. There were no entries in the Complaints book. Residents’ meetings are held in the home, and minutes are taken. Five meetings were held in 2005, and these covered a range of issues including meals, answering the phone and taking messages, planning activities and a trip out, and the garden. DS0000022799.V263226.R01.S.doc Version 5.0 Page 16 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, 27, 28, 30 The home is attractively furnished and decorated in a homely and comfortable style. Service users have spacious bedrooms, which they can personalise, and access to a range of communal areas. The home was clean to a high standard and well maintained, although some improvements were needed in food storage arrangements. EVIDENCE: The ground floor of the home contains a communal lounge, kitchen/diner, and a staff office. There is access to a large and attractive garden to the rear, which has a shed and garden furniture – residents confirmed that they spent time in the garden during the summer. The lounge was homely and attractive. The dining area is quite small, but adequate to meet residents’ needs as they do not all eat together. Residents comments included that they particularly liked the homely feel of the home. DS0000022799.V263226.R01.S.doc Version 5.0 Page 17 The middle floor contains the three residents’ bedrooms, a shared bathroom with toilet and bidet, and a separate toilet. Two residents showed the inspector their bedrooms, which were spacious and well furnished. One resident had a sofa, table and chairs, TV and entertainment system. The room was furnished with modern items that matched, and he confirmed that he had enough space for his belongings. The bathroom and toilet were very clean and nicely decorated. The top floor has a spare room that is used for storage, but it was reported that visitors would be welcome to use it if necessary. The Assistant Manager uses two other rooms as living space. Generally, the standard of cleanliness and repair in the home was high. Minor problems were observed in the kitchen. A small fridge had a loose handle, the inside light did not work, and the freezer compartment was frozen solid. The fridge should be defrosted and repaired, or replaced. Also, in the cellar, some bags of potatoes and rice had been left on the floor instead of on shelving (to deter pests). This was raised with the assistant manager who reported that these items are usually properly stored off the floor, but the extra supplies bought in for Christmas had led to an overflow. This must be avoided in future (see Requirements) DS0000022799.V263226.R01.S.doc Version 5.0 Page 18 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): 31, 32, 33 There are sufficient staff to meet service users’ needs, although the rota needs to be improved to clearly indicate who is on duty at the home and when. There are good and appropriate relationships between staff and service users. EVIDENCE: The Assistant Manager reported that he had worked at the home for two years. It is part of a small family-run business, and the owners also run two other homes in the near vicinity. Some of the staff work between the homes, and the rota that the inspector saw included all staff employed over all three. The rota was confusing to read, and did not form an accurate record of hours worked by staff in the home. This was discussed with the Assistant Manager, and is the subject of a new Requirement. As noted above, interaction that was observed between staff and residents was warm and appropriate, and residents were very positive in their comments about the staff team and the support that they gave. DS0000022799.V263226.R01.S.doc Version 5.0 Page 19 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, 41 The home is well run, although improvements are needed to records as noted in the report. Staff and service users benefit from the ethos of the home. EVIDENCE: The Assistant Manager demonstrated an in-depth knowledge of the routines of the home and issues relating to management and registration requirements. There was evidence that staff and residents benefit from the ethos of the home. As noted above, the rotas available in the home did not accurately reflect staff cover in the home, and this included management cover. The rota indicated that the Registered Manager worked at the home only twice a week, on Mondays and Fridays. The Assistant Manager reported that the registered manager visited the home almost daily. This must be clarified in the rota (See Requirements). The Certificate of Employers Liability Insurance on display in the hall was out of date. The Assistant Manager reported that this had been renewed, and that he would fax confirmation of this to the Commission. A Requirement is made that will remain in place until this confirmation is received. DS0000022799.V263226.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 4 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 3 X 3 3 X 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 2 X X X CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 4 Standard No 37 38 39 40 41 42 43 Score 3 X X X 2 X X DS0000022799.V263226.R01.S.doc Version 5.0 Page 21 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 YA6 Regulation 17(3)a Requirement The Registered Manager must ensure that care plans clearly indicate what support is being offered to service users by staff, which relates to goals and targets identified in Reviews. The Registered Manager must ensure that case files contain financial assessments of individual service users, and that detailed records are kept of any money held on behalf of any service user, any expenditure and/or balance held. The registered person must make sure that all medication received is recorded accurately at the time of receipt and a running total is kept on the medication sheet. Previous timescale of 12/10/05 partly met. Continuing non-compliance will lead to consideration being given to Enforcement Action. The Registered manager must ensure that medication is administered as prescribed, and that records correctly indicate if DS0000022799.V263226.R01.S.doc Timescale for action 01/05/06 2 YA6 Schedule 4(9) 01/04/06 3 YA20 17(1)a 01/02/06 4 YA20 13(2) 01/02/06 Version 5.0 Page 22 5 YA30 16(2)g 6 7 YA30 YA33YA37 16(2)g 23(2)c 17(2) Sch 4(7) 8 YA41 12 a dose is not administered to the service user. Clear procedures must be established that outline appropriate action to be taken when medication is refused or not administered, to ensure that the well being of the service user is promoted. The Registered Manager must ensure that the small fridge in the kitchen is defrosted and repaired, or replaced. The Registered Manager must ensure that dry goods are stored correctly at all times. The Registered Manager must ensure that a clear, accurate and up-to-date rota of staff is held at the home at all times, that includes the hours worked by the manager. The Registered Manager must ensure that an up-to-date Certificate of Employers Liability insurance is in place and on display. 01/03/06 01/02/06 01/02/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA19 Good Practice Recommendations The Registered Manager should take action to contact mental health organisations that offer information and support to service users, which could also act as a resource to staff. DS0000022799.V263226.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000022799.V263226.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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