Inspection on 07/12/05 for Evergreen

This inspection was carried out on 7th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 22/06/06

Evergreen 01/06/05

Evergreen 16/02/05

Evergreen 04/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Evergreen 290 Passage Road Brentry Bristol BS10 7HZ Lead Inspector Jacqueline Sullivan Unannounced Inspection 7th December 2005 10:00 Evergreen DS0000026590.V271565.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 Evergreen DS0000026590.V271565.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. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Evergreen Address 290 Passage Road Brentry Bristol BS10 7HZ 0117 9501791 0117 9501791 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) Treehome Ltd Ms Philippa Mary Waters Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 18 - 64 years with Learning Disabilities 16th February 2005 Date of last inspection Brief Description of the Service: Evergreen is owned by Craegmoor Healthcare. It is registered to provide accommodation and personal care for up to six people with a learning disability aged 18 - 64 years. A number of residents currently accommodated have complex needs which can result in challenging behaviour. The premises is situated in a quiet residential area. It is a small house that blends in well with the immediate surroundings. There are some shops and local amenities in the vicinity. The home also has a min-van which residents use frequently to go out. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the main purpose of which was to check on progress made to requirements made at the previous inspection. Opportunity was also taken to inspect the premises and check care plans. Evidence was gathered through discussion with the Area manager, manager and staff, inspection of records and observation. What the service does well: What has improved since the last inspection? The staff team are in a better position to protect the residents as risk assessments for individual activities have been reviewed to ensure that they are specific and detail the actual risk to the resident. A “reactive” strategy for each resident, which details trigger points, has been completed by the manager and the staff team. In addition staff have been provided with abuse awareness training and training in supporting individuals with challenging behaviour. This gives greater protection to vulnerable adults in their care. Individual risk assessments are in place. This means that the staff team are more aware of the work that needs to be in place to ensure the safety of the residents. The manager has started compiling an audit and provision of statutory training for staff. This means that she is able to assess more easily the gaps in staff training. Evergreen DS0000026590.V271565.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. Evergreen DS0000026590.V271565.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 Evergreen DS0000026590.V271565.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): 1 Advocates of prospective new residents do not have full information in the Statement of Purpose for them to make an informed choice about living at Evergreen. EVIDENCE: The Statement of Purpose contains the aims and objectives of the organisation and some of the facilities and services provided. The Area manager stated, following the inspection, that the new Clinical Goverence Team is in place. This is a specialist service developed by the organisation to assist the staff teams. For example, the team has a specialist in autism and will be coordinating the service and providing training. As a number of the residents currently accommodated in Evergreen have been diagnosed along the autistic spectrum, this will be a very useful resource. The manager needs to further develop the Statement of Purpose to include this development. Evergreen DS0000026590.V271565.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): 69 The residents’ care plans enable staff to provide consistent and individualised personal care. However, these need to be further developed to include social and emotional need so the home can more easily demonstrate it is meeting the needs of residents with more complex behaviours. EVIDENCE: Four residents’ files were inspected and were seen to contain life histories, risk assessments and individual care plans. Personal care needs included preferred activities, morning \ evening routines and support with nutrition and dressing. A recommendation was made at the last inspection about support needed in relation to residents’ learning disabilities and actions to be taken to help them manage their own behaviours. As previously noted the Clinical Goverence Team is now available to provide specialist service to assist the staff team. This information should be included in the residents care plans. Discussions with the manager and scrutiny of the risk assessments confirmed that they have been developed and reviewed. Individual activities are detailed to ensure that they are specific and determine the actual risk to the resident. The risk assessments are re assessed on a monthly basis. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 10 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 17 Residents are supported to go out and be part of the local community. They engage in appropriate leisure activities and have opportunities for personal development. Residents are offered a healthy diet. However the monitoring of the food that the residents actually eat could be improved. EVIDENCE: The residents attend a wide range of activities including evening activity clubs, pub evenings, and bowling and cinema trips. The manager stated that an arts and crafts worker will be employed to work fifteen hours with the residents. Around the home there was examples of the residents pottery and ceramic work. The manager stated there is lots of time for “tea and conversation “. The Area manager stated that there are plans to build a large freestanding gazebo that will be an activity centre for residents who are less able to go out into the community. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 11 The lunchtime meal, sampled at the inspection, was tasty and well presented. There was a choice of homemade vegetarian mince cottage pie with spinach and cabbage or vegetarian pies and vegetables. The residents choose to eat alone, or with the staff and other residents. A recommendation has been made in relation to the staff team recording the food that is actually eaten by the residents. This ensures that the staff are monitoring the residents welfare. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 12 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 There are good systems in place to ensure that residents’ health care needs are met. The medication policy needs to be updated to reflect the actual medication systems used by the staff team. EVIDENCE: Discussions with residents, members of the staff team and scrutiny of a random selection of the residents’ files confirmed that residents receive the support they require as detailed on their care plans. The manager has updated these plans to include whether residents prefer the help of a male or a female or who do not have a preference. The residents’ files confirmed that the residents receive the appropriate support to see the relevant healthcare professionals, including dentists, opticians and GPs. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 13 The medication system was inspected and it was seen that the gaps in the recording of medication administered, noted at the last inspection, have been rectified. The manager stated that she ensures that the records are more accurate. Since the last inspection the staff team have changed from the “blister pack” medication storage to the “nomad” system. She said this makes the administration of medication “quicker and less time consuming”. The home still needs to update the medication policy to reflect the care setting and current legislation (as required at the last two inspections). All staff have recently received training to ensure their competence to give out medication. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 The systems in place in order to protect the residents from abuse need to be further developed. The systems in place to ascertain the views of the residents need to be further developed. EVIDENCE: The residents’ care plan explained how residents preferred to be communicated with. This is important, as a number of residents are unable to directly verbally communicate their discontent. One resident stated that he knew how to complain if the need arose. The complaints systems were not examined at this inspection and will be a focus of the next inspection. However it was noted that residents meetings are taking place at intervals of every three months. As this is a forum whereby residents could express their concerns the frequency is not sufficient. A policy and guidance was seen. However there was no evidence that the staff team had read, understood and agreed to this policy. The staff files seen at the home evidenced that all staff have recently received training in supporting individuals with challenging behaviour. Certificates were seen on the files. A “reactive” strategy for each resident which details trigger points which may lead to challenging behaviour and actions taken to reduce the likelihood of this, has been completed since the last inspection. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 15 All staff files seen at the inspection evidenced the member of staff had received protection of vulnerable adults (POVA) training. However it was noted that this training is via a pack with an internal tick box questionnaire. As the residents accommodated at the home can exhibit complex and challenging behaviours a recommendation has been made that an external trainer further supplements this training. This ensures that the staff team have the opportunity to explore this area fully and ask questions. Evergreen DS0000026590.V271565.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): 26 27 28 Residents live in a comfortable environment. However the decoration and equipment in the residents’ bedrooms could be improved. EVIDENCE: The business plan for the home includes the gazebo and the introduction of a sensory garden. The Area manager stated that these would be in place next year. Since the last inspection the kitchen, which was previously in a poor state of repair, has been replaced. A new fridge and freezer has been purchased. The manager stated that there are plans to purchase new sofas for the lounge and to convert the current dining room into a quiet space for the residents. Six residents’ bedrooms were seen. They were mostly homely and many had televisions, pictures and photographs. One resident said he liked his room as he listened to his radio there. During the tour of the premises the following requirements were noted: • • The stained mattress in the top floor bedroom must be replaced. The carpet on the landing must be cleaned as it is stained. DS0000026590.V271565.R01.S.doc Version 5.0 Page 17 Evergreen One bedroom must be redecorated as the plaster is peeling and a schedule of redecoration is in place that ensures that there is a rolling programme of redecoration of the bedrooms. • A second chair must be available for visitors, either in the residents’ rooms or, if the resident chooses not to have this in place, then chairs available in the home. • The foil inset on one of the lights in the bedrooms is removed. An outstanding requirement in relation to the upstairs bathroom is carried forward to replace the lino. It was explained that additional work needs to be in place before the lino can be changed. As part of this work, the toilet has been moved so that the residents can use it more easily. All areas of the house were seen to be cleaned to a good standard. • Evergreen DS0000026590.V271565.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): Residents are supported by an enthusiastic staff team and there are sufficient staff on duty to ensure the needs of the residents are met. EVIDENCE: Rotas evidenced that there are now four support workers on duty all day until 4.00pm – this then reduces to three. Staffing levels do not go below these levels. Another team leader is joining the staff team shortly. The manager stated that this would allow her to delegate more tasks like supervision. A random selection of staff files were seen. These contained the required information including certificates of recent training. At the last inspection the personal file of the newest member of staff was seen. This person was employed from overseas and the manager was advised to obtain the organisation’s recruitment policy for overseas employees to ensure she had followed the appropriate procedure (for example in the obtaining of references). The manager said that she has seen this policy but was not able to find it on the day of inspection. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 19 It was also noted at the last inspection that that the newest employee had not completed their induction within six weeks and there were gaps in their training. The newest member of staff had started her induction but, as she had been in post for four weeks, the amount of induction completed indicated that, unless she works extremely hard in the next two weeks then the induction would not be completed in the six-week period. A requirement that the home improves standards in this respect has featured in the last two reports. The manager must ensure that the induction is worked through systematically through out the six week period, rather than leaving the majority of the work to the last few weeks. The manager provided evidence to indicate that all staff have received a CRB check and the newest staff have received a “pova” check. This meets with a requirement made at the last inspection. A selection of staff supervision records was seen. These indicated that the frequency of staff supervision is not consistent as some staff receive supervision every two months and for others there is a longer interval. Members of staff spoken with displayed a commitment and enthusiasm to their roles. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 20 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): Management systems need to be improved so that residents can benefit from a more organised and well run home. EVIDENCE: The manager has completed her NVQ Level 4. She stated that she is planning to start the Registered Managers award once she can ensure that she has the same tutor. She said that this tutor is familiar with the home. The manager has demonstrated a commitment to ensuring the work is in place to meet many of the requirements made at the last inspection. Where the requirement was not met there was evidence that the manager was working towards completion. However, any outstanding requirement from this report must be a priority. The home now has two team leaders (replacing the deputy post) to support the manager to fulfil her duties and to supervise staff. This should lead to further improvements. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 21 All staff spoken with said they felt the manager was fair and listened to them. The manager has worked hard to ensure that workplace risk assessments are in place. She was aware that these need to be developed for the home to demonstrate that the home is meeting with health and safety legislation. However further work needs to be in place to ensure the assessments are more detailed. For example the risk assessments seen in relation to holidays and trips need greater information for them to be a useful tool in the protection of the residents. All staff have training records – an examination of these indicated that many of the staff had received their statutory training of first aid, manual handling and food hygiene. The manager has started work in compiling an audit of statutory training needs and is arranging them accordingly. However until all the staff team have completed the mandatory training the requirement made at the last inspection, in relation to staff training, will remain in place. This will be a focus of the next inspection. There were records of fridge and freezer temperatures. There was an up to date insurance certificate and gas safety certificate. The fire logbook evidenced that the appropriate tests and checks are being made of the fire system. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 22 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 2 X x x x Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 x 2 3 x x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Evergreen Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x DS0000026590.V271565.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? 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 2 Standard YA1 YA20 Regulation 4 13(2) Requirement The Statement of Purpose is updated to include the specialist services available at the home. Update medication policy and ensure it is relevant to actual work practice within the home (REPEAT REQUIREMENT) Ensure all staff are aware of, and adhere to, policy on restraint Replace lino in upstairs bathroom (REPEAT REQUIREMENT) Ensure all new staff complete induction within set time limits (REPEAT REQUIREMENT) Manager to complete RMA Continue to develop workplace risk assessments (REPEAT REQUIREMENT) Ensure all the staff team have completed mandatory training accordingly Ensure all the staff team have supervision meets the required frequency. Ensure there is a rolling programme of redecoration of the residents’ bedrooms and the work listed in the “Environment” standard are completed. DS0000026590.V271565.R01.S.doc Timescale for action 02/02/06 02/02/06 3 4 5. 6 7 8 9 10 YA23 YA27 YA35 YA37 YA42 YA42 YA36 YA24 18(1)(c) 23(2)(b) 18(1)(c) 18(1)(c) 13(4) 18(1)(c) 18 16 02/02/06 02/02/06 02/02/06 02/02/06 02/02/06 02/02/06 01/01/06 03/03/06 Evergreen Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5 6 Refer to Standard YA6 YA9 YA34 YA27 YA23 YA17 Good Practice Recommendations Continue to develop care plans to include specialist support given Further develop individual risk assessments Become familiar with organisational policy on recruiting from oversees. Refurbish upstairs bathroom Additional Protection of vulnerable adults training is available. The staff team record the food that is actually eaten by the residents. Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Evergreen DS0000026590.V271565.R01.S.doc Version 5.0 Page 26 - 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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