CARE HOMES FOR OLDER PEOPLE
Evergreen 2 Brandreth Road Mannamead Plymouth Devon PL3 5HQ Lead Inspector
Jane Gurnell Unannounced Inspection 9th December 2005 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Evergreen DS0000003477.V259171.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Evergreen Address 2 Brandreth Road Mannamead Plymouth Devon PL3 5HQ 01752 665042 NO FAX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jacqueline Denise Tope Mr Roy Richard Tope Mrs Jacqueline Denise Tope Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Age 60 Date of last inspection 23rd June 2005 Brief Description of the Service: Evergreen is situated within walking distance of Mutley Plain shopping precinct in Plymouth. The establishment is formed from two terraced Victorian villas that have been internally combined. The home has a family atmosphere due to the efforts of the owners and the staff, and because the home can only accommodate sixteen residents at any one time this ensures a non-institutional atmosphere. The home has the category of OP (older person) and has neither of the specialist categories for the provision of dementia care or severe physical disability. The home specialises in creating a homely environment to meet the individual needs of each resident. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over on 9th December 2005. Mr and Mrs Tope, the owners of Evergreen were present during the inspection and they and their staff team assisted the inspector throughout the inspection. The focus of the inspection was to consult with the residents and review the care planning processes and related documentation. The inspector spoke to 13 residents, toured the building and examined care records and other documents relating to health and safety issues. What the service does well: What has improved since the last inspection? 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 DS0000003477.V259171.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 7 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 Thorough and comprehensive systems for admission allow residents and their relatives to be confident that their needs can be met. EVIDENCE: Assessments were undertaken to identify residents’ needs prior to admission and these were evident for a newly admitted resident. Residents said that they and their families had been able to visit the home before they had moved in and had been made very welcome. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 8 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10, Residents’ health, personal and social care needs are being met and residents are treated respectfully. EVIDENCE: Residents said they could not be treated better and described living in the home “lovely” and “excellent”, with one resident saying “it was as close to your own home as you could get”. Those care plans examined detailed residents’ care needs and included risk assessments relating to activities of daily living, mobility and falls: there was evidence that these had been updated when residents needs changed. One resident described how her health had improved significantly since she had come to live at Evergreen, due to the care and support she was receiving from the staff. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Residents are supported to maintain their independence and chosen lifestyle. EVIDENCE: Residents described that they are encouraged to come and go freely from the home and to maintain contact with family and friends. The residents said that they looked forward very much to the weekly visits from the children from the local primary school, who visit to undertake crafts and activities. The residents have been invited to visit the school to attend the carol service and to accompany the children to the local church. The Residents said that the meals were very good and that they were consulted about the menu planning. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 10 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Complaints and suggestions from residents, relatives or other visitors to the home, are treated seriously. Residents are listened to and issues resolved promptly. EVIDENCE: Residents said that the owners and staff were very approachable and they were confident that any issues of concern would be listened to and dealt with. No complaints since the last inspection. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 11 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25, 26 Residents live in a pleasant, well-maintained home that is comfortable and warm and which provides sufficient facilities to meet their needs. EVIDENCE: All communal rooms and bedrooms were pleasantly decorated and furnished, reflecting the period of the building. Residents said that the home is always very clean. Residents are provided with a small safe to store valuables and locks have been fitted to some bedroom doors. Radiators identified as posing a risk of burn injuries to residents have been covered. Mrs Tope said that hot water control valves had been fitted to baths to reduce the risk of scalding. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 12 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Residents are cared for by well-trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. EVIDENCE: Residents described the staff as very kind and caring and confirmed they responded promptly to requests for assistance. At the time of the inspection there were 3 care staff and 1 domestic staff on duty as well as the owners who work in the home 6 days a week. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 13 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 37, 38 Residents live in a well managed home. The owners and their staff team strive to provide a homely, stimulating and safe environment that respects and protects residents’ rights. EVIDENCE: Residents said that they feel safe and secure in their home and that the home was well managed. Mr and Mrs Tope are available each day, including weekends and meet with residents and staff on a daily basis. Fire safety training for staff was documented and included unannounced fire training drills to ensure staff were aware of their responsibilities should a fire be discovered. The kitchen and food store areas were found to be clean and tidy indicating that regular cleaning takes place. Records of any accidents to residents and staff were recorded and Mrs Tope monitors these to for any indication of changing needs.
Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 14 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 4 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 3 3 Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 15 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP24 Good Practice Recommendations Door locks should be fitted to bedroom doors of a type that do not require a key from the inside and can be overridden by staff in an emergency. Evergreen DS0000003477.V259171.R01.S.doc Version 5.0 Page 16 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 DS0000003477.V259171.R01.S.doc Version 5.0 Page 17 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
