Inspection on 11/01/08 for Evergreen House

This inspection was carried out on 11th January 2008.

CSCI found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Evergreen House 12/06/09

Evergreen House 16/06/08

Evergreen House 26/06/06

Evergreen House 08/11/05

Evergreen House 29/06/05

Evergreen House 02/11/04

Evergreen House 27/07/04

Evergreen House 07/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Evergreen House Lichfield Road Tamworth Staffordshire B79 7SF Lead Inspector Dawn Dillion Key Unannounced Inspection 11th January 2008 10:10 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 House DS0000004939.V356365.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen House Address Lichfield Road Tamworth Staffordshire B79 7SF 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) 01827 50675 01827 50120 Mrs Kailash Jayantical Patel Mr Jayantical James Bhikhashai Patel Mrs Gail Margaret Ghadially Care Home 28 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (28), Physical disability (10) of places Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To permit admission of a specific male service user aged over 60 years for the categories DE and PD (REF Application No. 42045) 1 PD (Physical Disabilities) - Minimum age 56 years for planned respite care breaks 26th June 2006 Date of last inspection Brief Description of the Service: Evergreen House is residential home located in Tamworth, Staffordshire that provides a service for older people. The homes registration category enables them to offer a service to individuals suffering with dementia or people who have a physical disability. The home is situated in a residential area and is in keeping with the local community; Evergreen House is accessible via public transport and is close to local amenities. The large mature three storey-detached property provides accommodation for twenty-eight people on the ground and first floor level. The home comprises of sixteen single occupancy and six shared bedrooms. En suite facilities are not provided, however, bathrooms and toilet areas are situated in close proximity to bedrooms and communal areas. The Registered Manager/Administrator’s office is located on the second floor, which is not accessible to people living in the home. There is a passenger lift in place, to enable people to access all the facilities within the home. Ramp access is provided at the rear of the property only. Situated on the ground floor is a separate dining area, a compact lounge and a large conservatory that is utilised as a lounge, all areas of the home is equipped with essential furnishings and fitments to promote the comfort of the individual. The home also provides a large industrial kitchen and there is a separate laundry room. People using the service have access to a secure garden at the rear of the property. Ample car parking is available at the front of the property. Staffing is provided on a twenty-four hour basis, to ensure the total supervision and support of people living in the home. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 5 There was no written information in the home relating to the fees chargeable for the service provided at Evergreen House. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced Key Inspection of Evergreen House was undertaken within 9.5 hours. The inspection methodologies that were used, to establish the quality of care provided and the effectiveness of the management of the home, to promote equality, diversity and best practices entailed the examination of the records, relating to the homes policies and procedures. Three people who use the service and two staff members were interviewed during the process of the inspection, to ascertain their views in relation to the service delivery. Comments were also obtained from a District Nurse. A tour of the property was undertaken, to ensure that the environment and systems in operation were safe and conducive in meeting the needs of the people using the service. The Registered Manager was present during the process of the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. What the service does well: What has improved since the last inspection? Discussions with the Registered Manager confirmed that the home were currently in the process of implementing of new care plan format, to provide more detailed information, relating to the care needs of the individual. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 8 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 House DS0000004939.V356365.R01.S.doc Version 5.2 Page 9 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 House DS0000004939.V356365.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People wishing to access the service were provided with information, to enable them to establish, whether the service provided within the home would meet their assessed needs. The lack of consistency with the undertaking of assessments could have a negative impact on the level of care provided to people. EVIDENCE: The homes Statement of Purpose and Service User Guide was combined and provided essential information, relating to the service and provisions available Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 11 at Evergreen House. The document incorporated pictures of people living in the home and also staff members. The Registered Manager should ensure that consent is obtained from the individuals for the pictures to be used before publication. Information relating to the fees chargeable for the service and provisions provided at the home were not identified within the document. Discussions with the Registered Manager and the examination of three records pertaining to individuals who had recently been admitted to the home, identified that one Care Management Assessment (Pre Admission Assessment) had not been signed or dated and that one person was admitted without an assessment. The examination of care plans identified that people living in the home had access to other healthcare services, it was however, of concern that very little emphasis was focused on aids and adaptations to assist individuals who have a sensory impairment. An assessment undertaken by a placing Social Worker, in view of one person accessing the service, identified the need for the intervention of a Community Psychiatric Nurse, this information was not incorporated within the persons care plan and discussions with the Registered Manager confirmed that this had not been carried out. The Registered Manager confirmed that people wishing to access the service were able to visit the home prior to admission. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of consistency in the reviewing of care plans and the absence of risk assessments, failed to demonstrate whether peoples needs were being met appropriately. Inappropriate storage of prescribed medication compromised the health and welfare of people living in the home. EVIDENCE: The Registered Manager informed the Inspector that the home were currently in the process of reviewing care plans, to implement a new format which, would provide more detail, regarding to the specific needs of the individual. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 13 Three care plans pertaining to people who had recently been admitted to the home were examined. All provided information relating to the level of support and assistance the individual required to promote their independence. There was a lack of consistency in reviewing care plans, to reflect the individuals changing needs. There was also no evidence, that people were actively involved in the development or the review of their plan of care. Discussions with the Registered Manager and the examination of records confirmed that people living in the home, did have access to healthcare services. During the process of the inspection a District Nurse was interviewed, who confirmed that the home did share relevant information, relating to the health needs of the individual. Information received from the District Nurse identified that a person living in the home had sustained a scald from a hot beverage and was currently receiving some nursing intervention. Albeit that this incident had been recorded on an accident form, this information had not been shared with the Commission for Social Care Inspection. The Registered Manager confirmed that this incident had been addressed with the staff team. There was no written evidence of this, with regards to minutes of staff meetings or supervision notes. There was also no risk assessment in place for this individual, to prevent or reduce the possibility of this occurring again. Discussions with the Registered Manager, confirmed that there were no risk assessments in place for the individual person living in the home. With reference to the homes medication arrangements and practices, the Nomad monitored dosage system was in operation. Discussions with a Senior Carer who was responsible for the administration of medicines, confirmed that she had received training within this area. The examination of the medication administration records identified that there were no signatory gaps. A fridge located on the first floor containing medicines was unsecured and the contents was accessible to people living in the home and to visitors. The Inspector raised concerns that the insulin contained within this fridge, was not labelled or contained in a box to identify who it had been prescribed for, the Registered Manager removed it immediately. With regards to privacy and dignity, discussions with the Registered Manager confirmed that privacy screening was provided in the shared bedrooms, the Inspector observed this during the tour of the property. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 14 During the process of the inspection, a member of staff was observed entering bathrooms/toilet areas on three separate occasions, without knocking on the door and on all occasions these areas were occupied. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home had access to limited social activities, the lack of systems in operation, to enable individuals to be involved in the management of the service delivery, failed to demonstrate whether people had a choice or were able to make decisions about their lifestyle and welfare. EVIDENCE: Discussions with the Registered Manager confirmed that there were no individuals in residence from the ethnic minority group. The home would make every effort to meet the needs of people who have specific cultural or religious needs. The home also provided a service for people, who suffered with dementia, staff had received dementia awareness training but there was no evidence of a Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 16 specific service, or dementia care planning with regards to this specialist area of care. Located in the corridor was a ‘Path of life’ a detailed pictorial reminiscence on life through the ages. General observations during the process of the inspection, identified that people living in the home, enjoyed reading and looking at the pictures, which provoked conversation about their life and family. Members from the local churches visited the home on a regular basis; to enable the individual to continue to practices their religious/spiritual faith. An activities person attended the home three times a month, providing social activities, such as music therapy. One person who lived at the home said, “I don’t go out much, I prefer to stay in my room.” I can have visitors at anytime, I would recommend living here, I’m comfortable, I have no complaints.” People living in the home were not involved in meetings, to enable the individual to have an input into the management of the home, in view of the service delivery, decision making or choice. The Registered Manager also confirmed that people did not have access to an independent self-advocacy service. The home operated a weekly menu; discussions with the Registered Manager confirmed that there were no special diets required with regards to culture or religion. A variety of well-balanced nutritional meals were provided. Appropriate aids were available to assist individuals with eating and drinking to promote their independence. A report from the Environment and Regulatory Services identified a requirement that staff should receive training linked to food safety management procedure. The Registered Manager confirmed that this training had not yet been commissioned. One person living in the home informed the Inspector that, “The food is sometimes what I don’t like but other times it is very good.” Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns/complaints and have access to the homes complaint procedure; the lack of familiarity with regards to adult protection protocol could result with people being vulnerable in the home. EVIDENCE: The homes complaint procedure was accessible to all people living in the home, the document was located in each bedroom. The Commission for Social Care Inspection have received two complaints relating to the home in recent months. One complaint was redirected to the home, for them to conduct their own enquires. The other complaint was regarding staff bringing their dogs to the home and concerns about infection control and health and safety. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 18 Enquires undertaken by the Commission for Social Care Inspection, established that dogs did frequent the home and that there were no risk assessments in place, with regards to tripping hazards, allergies, infection control or people’s general fear of dogs. The complainant also raised concerns that no senior staff were provided on a specific date. The examination of the staff working rotas and discussions with the Registered Manager confirmed that she was on duty that day. An abuse and the Staffordshire Inter Agency policy was in place, discussions with the Registered Manager identified that there was a need to become more familiar with the appropriate actions to be taken, in the event or suspicion of abuse. The examination of staff records confirmed that appropriate safety checks were undertaken, prior to the commencement of employment, to ensure the safety of people living in the home. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The design and layout of the property was suitable to meet the needs of people living in the home. Poor heating in the lounge and domestic pets accessing bedrooms and the kitchen compromised people’s comfort, welfare and safety. EVIDENCE: Evergreen House is located in Tamworth, Staffordshire, situated in a residential area and was in keeping with the local community. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 20 The large mature three storey detached property is set within its own grounds, the home comprised of sixteen single occupancy and six shared bedrooms located on both the ground and first floor level. The bedrooms that were inspected were equipped with essential furnishings and efforts had been made to personalise the individual rooms. En suite facilities were not provided; bathrooms and toilet areas were situated on both floors, equipped with an assisted bath and appropriate aids to assist individuals who have a physical disability. The Registered Manager/Administrator’s office was located on the second floor, which was not accessible to people living in the home. There was a passenger lift in place, to enable people to access the provisions/facilities within the home. Ramp access was provided at the rear of the property only. Situated on the ground floor was a separate dining area, a compact lounge and a large conservatory that was utilised as a lounge. The Inspector raised concerns that the conservatory was cold, which was confirmed by two people who lived at the home. The home also provided a large industrial kitchen and a separate laundry room. People using the service had access to a secure garden at the rear of the property. Ample car parking was available at the front of the property. With reference to aids and adaptations, the examination of the homes records identified that ten bed guards were in use, with only eight risk assessments in place. Records relating to safety checks of bed guards dated September 2007 stated that four guards were loose. There was no evidence that any action had been taken, to ensure that these appliances were safe. It is also of concern that the manufactures instructions, relating to the appropriate fitment of these appliances were not accessible to staff. An immediate requirement was issued on the day of the inspection, to ensure that an audit was conducted on all bed guards and that appropriate risk assessments are in place. The general cleanliness of the home was satisfactory, however, due to a recent complaint about dogs accessing bedrooms and the kitchen, which was confirmed by the Registered Manager, raises concerns about infection control. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 21 Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were provided in sufficient numbers, to ensure the support and supervision of people living in the home. The deficiency in the implementation of induction programmes and supervision compromised the standard of care provided to people. EVIDENCE: The examination of staff working rotas and discussions with the Registered Manager confirmed that adequate staffing levels were provided to meet the needs of people living in the home. The Registered Manager informed the Inspector that 48 of the staff had obtained the National Vocational Qualification level 2 or 3 in care. Three files pertaining to people working in the home identified that the appropriate safety checks were undertaken, prior to the commencement of employment. Albeit that the home had a structured induction programme in place, this was not being carried out. It is also of concern that staff did not receive regular supervision. There was also no evidence of staff meetings taking place. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 23 The examination of records identified that staff had received training in moving and handling, fire awareness and dementia in 2007. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management and administration of the home provided insufficient support to staff, which had a negative impact on the service provided. Poor quality assurance systems failed to identify the short fallings within the home. EVIDENCE: The Registered Manager was experienced in social and healthcare and she continued to undertake periodical training, to keep abreast of issues relating to elderly care. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 25 The Registered Managers office was located on the second floor, which was not accessible to people living in the home or a suitable location to monitor the service delivery. One member of staff said, “the management support is very good and the training is good.” Another member of staff confirmed that, “if you need to discuss anything with the Manager she is approachable, the management support is alright.” Service users questionnaires were distributed to people living in the home, to ascertain their views and opinions, in relation to the general service deliver, comments received were positive. There was no evidence that the information collated from the questionnaires were fed back to people, or how the information was used to improve the service delivery. There were a number of short fallings of which, compromised the quality of the service delivery and this was not encapsulated within the homes quality assurance model. With reference to peoples finances, a small amount of cash was maintained in safekeeping, two accounts and funds were examined both were satisfactory. Receipts were not maintained for expenditures made on behalf of individuals. As previously identified within the contents of this report, staff members were not provided with regular supervision. With reference to systems and practices that promoted the health and safety of people accessing the service, the examination of records identified routine safety checks were carried out on electrical and gas appliances. A fire risk assessment was in place, this was not dated and did not reflect the new smoking law, the level of risks or the appropriate control measures. To promote best practice to staff, the Registered Manager should refrain from wedging fire doors open. Discussions with the Registered Manager confirmed that a number of people occupying the first floor were non ambulant. There were no individual evacuation plan in place, or any contingency plans, in view of the fact that there were only two staff members provided throughout the night. During the tour of the property it was noted that COSHH (Control of Substances Hazardous to Health) chemicals, were not maintained securely. A chemical substance was also decanted into another bottle. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 26 A locking device was not fitted to the door of the linen cupboard and it was also noted that there was no smoke detection installed in the cupboard. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 1 X X 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 1 1 X Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 28 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. 1. Standard OP29 Regulation Schedule 2 Requirement The registered person shall ensure that all the records required on the staff were completed prior to employment. (Outstanding from 31/07/06). There was a lack of consistency in ensuring that people were subject to a Care Management Assessment, prior to being admitted to the home, to ensure that they receive the appropriate level of care. The registered person should take the necessary measures to ensure that people are assessed prior to admission, to establish the individuals care needs. 3. OP4 13(1)(b) A person living in the home did not have access to a Community Psychiatric Nurse as identified within their assessment. The registered person should take the appropriate actions to ensure that people have access to relevant healthcare professionals, to meet their Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 29 Timescale for action 29/02/08 2. OP1 14 29/02/08 29/02/08 4. OP8 37(1)(c) assessed needs. A person living in the home received injures and required medical intervention, this incident was not reported to the Commission for Social Care Inspection. The registered person should review the homes protocol to ensure compliance with regulation 37. There were no individual risk assessments in place. The registered person should take the necessary actions to ensure that all activities undertaken by people living in the home, is reasonably practicable free from hazard. Prescribed medications were maintained in an unsecured fridge. The registered person should take the necessary measures to guarantee the safekeeping of medicines, to ensure the safety of people accessing the service. 29/02/08 5. OP8 13(4)(a)( b)(c) 28/02/08 6. OP9 13(2) 29/02/08 7. OP9 13(2) Insulin contained within a fridge was not labelled or contained in a box to identify who it had been prescribed for. The registered person should take the necessary actions to make sure that medicines are stored and recorded appropriately, to ensure the health and safety of people receiving medication. 28/02/08 8. OP8 13(4)(a)( b)(c) A person living in the home sustained a scald; there was no risk assessment in place. DS0000004939.V356365.R01.S.doc 28/02/08 Evergreen House Version 5.2 Page 30 9. OP26 13(4)(a)( b)(c) The registered person should ensure that the appropriate measures are taken to reduce or eliminate the risk of scalds. Dogs within the home were able 29/02/08 to wander into bedrooms and the kitchen. In the interest of infection control, health and safety, the necessary measures should be taken to reduce the dog’s access in the home. Staff members did not receive regular supervision. The registered person should take the necessary actions, to ensure that staff are supported within their roles. 10. OP36 18(2) 01/03/08 11. OP22 13(4)(a)( b)(c) A number of bed guards were in 14/01/08 use, the homes records identified a defect with the fitment. There was no evidence of any action taken to ensure that these appliances were safe. Staff also did not have access to the manufacturers instructions regarding the appropriate fitment. The registered person is required to take the appropriate measures, to ensure that people’s health and welfare are guaranteed when using these appliances. 12. OP22 OP38 13(4)(a)( b)(c) There were no risk assessments in place for the use of bed guards. The registered person is required to ensure that the necessary 14/01/08 Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 31 13. OP25 23(2)(p) measures are taken to guarantee that people are free from any hazard to their safety. Insufficient heating was provided 28/02/08 in the conservatory. The registered person should ensure that the appropriate actions are taken to maintain an adequate level of heating, in the interest of people’s general comfort and wellbeing. There was a lack of consistency in reviewing of care plans. 14. OP6 15(2)(b) 29/02/08 15. OP38 23(4)(a) The registered person should ensure that the necessary measures are taken; to make sure that people’s care needs are being met appropriately. The homes fire risk assessment 29/02/08 did not identify the date, the level of risk or appropriate control measures. The registered person should take the appropriate action to ensure that the fire risk assessment is robust and effective. There were a number of people located on the first floor who were not ambulant. There were no evacuation or contingency plans in place. The registered person should ensure that systems are in place to evacuate people in the event of a fire. There was no evidence of any systems or practices in place, to promote the individual’s choice, social inclusions or to enable the individual to make decisions, in areas affecting their lifestyle and welfare. DS0000004939.V356365.R01.S.doc 16. OP38 23(4)(b) 29/02/08 17. OP12 OP14 16(2)(m)( n) 23/03/08 Evergreen House Version 5.2 Page 32 18. OP30 18(1)(a)( 2) The registered person should make the necessary arrangements, to ensure that the delivery of service reflects people’s social, cultural and emotional needs. New staff members were not 23/03/08 inducted into their post. The registered person should take the necessary actions to ensure that people working in the home are provided with the appropriate skills and support to undertake their roles effectively. 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 OP33 Good Practice Recommendations Consideration should be given to provide a system to ensure that people receive feedback from service user questionnaires and that information collated is used to improve the service delivery. The registered person should ensure that consent from people whose photographs have been used in the homes Statement of Purpose and Service User Guide is obtained before publication. To preserve the total privacy and dignity of people living in the home, the registered person should ensure that staff are aware of the basics of knocking on doors before entering toilet, bathrooms and bedrooms. The registered person should ensure where possible that people living in the home are given the opportunity, to be actively involved in the development and review of their care plan. Systems and practices within the home should be reviewed to promote equality, diversity, rights and the choice of people living in the home. The appropriate measures should be taken, to ensure that people living in the home have access to an independent DS0000004939.V356365.R01.S.doc Version 5.2 Page 33 2. OP1 3. OP10 4. OP7 5. 6. OP14 OP14 Evergreen House 7. OP14 8. 9. 10. 11. 12. 13. OP35 OP8 OP4 OP18 OP38 OP38 self-advocacy service. To ensure that people living in the home are able to make decisions about their lifestyle and welfare, it is recommended that meetings are held to enable the individual to have a say in the management of the home. Receipts should be maintained for any expenditure made on behalf of people living in the home. Care planning, practices and environmental factors should be reviewed to ensure that people who suffer with dementia are catered for appropriately. Consideration should be given in reviewing systems in the home to assist people who have a sensory impairment. The Adult Protection Policy should be reviewed by all staff to ensure that staff are aware of the necessary protocol to follow in the event or suspicion of abuse. The practice of wedging fire doors should cease. Consideration should be given to provide a locking device on the linen cupboard door. Evergreen House DS0000004939.V356365.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 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 House DS0000004939.V356365.R01.S.doc Version 5.2 Page 35 - 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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