Inspection on 16/06/08 for Evergreen House

This inspection was carried out on 16th June 2008.

CSCI found this care home to be providing an Adequate 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 11/01/08

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 Keith Jones Key Unannounced Inspection 16th June 2008 09:00 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 House DS0000004939.V363930.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.V363930.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.V363930.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th January 2008 Brief Description of the Service: Evergreen House is located in Tamworth, Staffordshire. It is situated in a residential area and is accessible via public transport and is close to local amenities. The service provides care to older people some of whom may have a physical disability or dementia care needs The three storey-detached building provides accommodation for twenty-eight people on the ground and first floor level, comprising of sixteen single and six shared bedrooms. Although en- suite facilities are not provided bathrooms and toilet areas are situated close to bedrooms and communal areas. The ground floor offers a separate dining area, compact lounge, and a large conservatory that is utilised as a lounge. All areas are equipped with essential furnishings and fitments to promote the comfort of people who use the service. A passenger lift enables people to access all floors. Ramped access is provided at the rear of the property only. Ample car parking is available at the front of the building secure gardens to the rear. The full range of charges were not detailed in the service’s ‘statement of purpose’ or service user guide’ documents as they should be. The reader may wish to contact the service to obtain this information. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection was conducted over eight hours by one inspector, with the Care Manager, an ‘expert by experience’, and senior care staff. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in, or use the service. All the Key National Minimum Standards were inspected or reviewed. We had the full cooperation and contribution of staff and residents present. The expert by experience was briefed of general factors regarding Evergreen House, and was given free access to all residents to discuss issues of mutual interest. The last inspection report was discussed, and it was noted that outstanding requirements and recommendations from that visit had been addressed satisfactorily. There has been a significant consolidation and improvement in the planning, review and implementation of care standards. We acknowledged receipt of the Annual Quality Assurance Assessment (AQAA), a self-assessment that is filled in once a year by all providers. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. We also received seven quality survey returns, mainly complimentary, with some constructive comments: “S. is very happy with the care he receives”,” Care seems to be OK, staff are friendly and good to residents”, ” Lot happier with my mum’s care, all staff seem helpful and caring”, “ M’s personal care and hygiene is good, she is warm and comfortable”, “ I have complete trust and peace of mind in Evergreen’s care”, “ I think a few more social activities could be provided, and some entertainment now and again.” On the day of inspection there were 27 people in residence, of which we case tracked three, which confirmed the establishment of a comfortable and caring home. The tour of the home was carried out in a relaxed, courteous and professional manner. The expert by experience had access to talk with, and share daily life with a number of residents. Relatives who were present were complimentary of the family approach to care, the freedom they enjoyed and the involvement that the manager and her staff encouraged. Everyone appeared comfortable and at ease with their surroundings. We also examined a sample review of administrative procedures, practices and records, confirming an adequately consistent practice, and management. We received a report from the expert by experience, who wished it be known that she had found that: Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 6 “Evergreen House provides a homely and safe environment for the residents who live there. All of the residents were happy with the level of care they receive and found the staff friendly.” A full verbal report was offered at the end of the inspection to the Care Manager. What the service does well: What has improved since the last inspection? What they could do better: We consider that further improvements can be made in the way that information is provided to prospective people and families. Maintenance and accessibility to the Statement of Purpose and Service User Guide documents is required. We recommend that regular meetings with people who use the service and their relatives are held to promote communications, and provide a forum to explore issues of concern. Although a program of activities has been introduced, these do not meet the needs of less able people. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 7 Although significant achievements have been made in relation to record keeping and quality monitoring further work is needed to make sure that the service is being run in the best interests of those who use it. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 8 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.V363930.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4,5 and 6. The quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The needs of prospective people are appropriately assessed before they are offered a place. They and their relatives can be confident that the service will be able to meet their needs. EVIDENCE: The updated Statement of Purpose, and Service User’s guide give a satisfactory description of the home’s aims and objectives, philosophy of care and terms and conditions and are supported by an informative brochure. These documents offer people the opportunity to make an informed choice about the service’s suitability for them. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 10 We found that the documents as they were kept in the manager’s office, were not accessible enough. We suggested that the documents should be offered to all enquirers, and a copy put in each bedroom for people to read. We advised that the Service user guide be produced in an audio version to compliment the large print version already available. Fees presented to private applicants are to be included in the Guide. Both documents need to present the up to date CSCI and support contact addresses. The Statement of Purpose is supported by a contract, which indicates the terms and conditions, which are discussed with people prior to their admission. We told the manager that the bedroom number for each person should be detailed in his or her contract. Both documents need to present the up to date CSCI and support contact addresses. The service told us in their Annual Quality Assurance Assessment (AQQA) that: “Before agreeing admission the needs of the individual are carefully considered to ensure that we can provide for their needs. Care plans from Social Services are also obtained to assist us further with assessing needs”. We found this information to be correct. We ‘case tracked’ three people who use the service. This process confirmed that the Care Manager or deputy carries out a pre-admission assessment before any new person is offered a place. The assessments looked at the individual needs of each person taking into consideration culture, social and personal needs. Using the information the manager makes a judgement as to the suitability of the service against the needs of each prospective person. A plan of care based on personal needs and daily living processes is then produced from the assessment information obtained. No people were receiving intermediate care at the time of inspection. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the service provides a good standard of health care, record keeping to further evidence this could be improved upon. Although people are respected and their dignity is maintained, improvement in the promotion of privacy is needed. The care team maintain safe and secure medicine administration systems. EVIDENCE: We found that the pre-admission assessment enable informative care planning processes. We tracked three people’s care files, these held detailed information for each individual. The care files showed us their life style (path Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 12 of life) needs, events and contacts, procedures and actions are measured on a daily basis and are reviewed monthly. We saw that the service’s recent reestablishing of risk screening is effective. We observed that the system of daily monitoring (a checklist and tick box system) was subject to the capacity of individual staff members. When events need recording a senior member of staff or manager record the issue in the ‘monthly report’ summary, and review the care plan. The situation is containable, although dependent on an ever-present manager. We were presented with an example of a daily hand written log record, kept on the person of the senior carer, which identified the literacy challenge. This is retained as a contemporaneous log of events. We suggested that the monthly report be replaced by a weekly report to better keep track of the care provided and any other events that may occur. Staff training should continue to improve their written report skills. Six people are cared for in bed, they have a variety of health and mobility needs. Records of doctor visits and District Nurses interventions confirmed their dependency needs, none are assessed as requiring nursing care. All of these six people have been reviewed with family members, with an understanding ‘that their needs will be met by the service wherever possible, rather than moving on to a nursing home’. This means that there could be a pressure on care resources. Continence is assessed on admission and promoted within the plan of care. We saw evidence that resident’s nutritional needs, and weights were frequently reviewed. Care staff maintain all aspects of people’s personal care, overseen by the care management on a daily basis. We observed courteous interaction between people and staff, based on a level of confidence of mutual trust and respect. Comments received by our expert by experience confirmed the warmth of the caring atmosphere, and daily interactions. Discussions with people confirmed their acceptance and confidence in the overall standard of care and service given: “ Everybody is really friendly and kind, I don’t know where they get the patience from”, ” Personal care of mum is very good, the carers do a brilliant job” One relative told us “Personal care is, in the main, very good, (however) on occasions my father has been unshaven”. Our observation of personal care indicated close attention given to mouth, eye and skin care, dress and grooming was, by and large of a good standard. We observed one person to be unshaven, and had dribbled his tea and biscuit residue on to his clothes. He maintained he was “….fine, and didn’t want any fuss. I don’t want to shave today, I’m alright.” Carers were seen to interact with people with purpose and compassion. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 13 The policy of the service is to maintain peoples’ own doctors wherever practical; otherwise they are registered with the local surgery. District nursing services are received frequently, and the service has an established, and positive rapport. It is stated in the service’s Statement of Purpose and the AQAA, that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of residents. However, one person that:” Possibly better liaison with relatives” may help. Our expert by experience stated: ” There was however a lack of resident involvement in the running of the home, I was not aware of any resident meetings or much communication between staff and residents other than within a care task”, which tended to support the concern, to match the statement of intention. It was confirmed that attempts to set up relatives and residents meetings had not been successful. We suggested that further attempts should take place, on a three monthly basis. There was evidence that suitable equipment was deployed effectively, there is a chronic storage problem in the Evergreen house, with new storage cabinets taking valuable corridor space, along with working portable hoists. A suitable wheelchair store is available, and we saw that all care equipment was suitably maintained. Bathroom and toilet facilities have notices attached for staff to check occupancy before entering. Privacy and dignity would be improved if an engaged signal or lock were provided on these doors. We looked at bedrooms presented to facilitate privacy for the individual, which included medical examinations and personal care procedures being performed in private. There is a need to facilitate a suitable door lock for dementia care situations, to enable selective periods of privacy, without prejudicing safety. Lockable facilities are available on demand, and we saw several ‘metal money boxes’ in place, although they needed fixing to a secure surface. Double bedrooms need a privacy screen or curtain beyond the wheeled screen available. Curtains that have been on order for four months must be chased up as a matter of urgency. We examined the administration of medicines, which adheres to procedures to maximise protection to residents. The storage in a chain secured metal medicine trolley, within a corridor is adequate. The supporting pharmacist documentation, although in place, needs a review to remove surplus and outdated information. The controlled drug management would be improved with the provision of a Rag-bolted metal cabinet. A controlled drug register is to be obtained and available should the need arise. There were no people on controlled drugs at the time of inspection. We saw that medicines were being administered effectively, with no breaks in continuity. We found the receipt of Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 14 drugs, storage, accountability, and disposal of unused medicines was audit trailed, accurate and appropriate. There were no people self-medicating at the time of inspection. The medicines fridge was secured and used appropriately, monitored on a daily basis. Evergreen House DS0000004939.V363930.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): 12,13,14 and 15 The quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People’s rights to live a meaningful life are central to the homes aims and objectives. Activities and socialisation need to match this expectation. People are offered a healthy, well balanced diet, with choices for every meal. EVIDENCE: Our discussions with people and staff identified a relaxed atmosphere in which their needs were seen to be respected. We considered the routine exists to establish a framework for managing the home, not as a regime for people to comply with, but for a point of familiarity. Activities are a considered to be a key element in the socialisation approach to care, with visitors encouraged to be involved in a partnership style with care staff. However the actions are not as robust. The service stated in their AQAA submission that: “Service users are encouraged to take part in meaningful daytime activities according to their own choice and capabilities.” Yet recognise: “Providing Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 16 entertainment and engaging the service users in physical activity is another on going struggle at Evergreen. Although a few residents will join in with activities it is generally very difficult to get the majority of people to take part. When outings or activities are offered they are often refused”. They hope to accommodate this inertia with “We also realise that some in-house training on the need for physical and mental activity is needed. We have recently purchased some painting and craft equipment and will offer this activity to service users in the very near future”. We found sufficient evidence to show that activity schedules and plans fail, ostensibly because people don’t want to be bothered, whereas the reality is that there are pressures on staff time given over to higher dependency care, at the expense of activities. Attempts are haphazard thereby leading to low expectations from people who use the service. We acknowledge resources are available to provide ad hoc entertainers, and a person to come in three times a month. There is little attempt to offer a therapeutic service in manipulative skills, and people who have greater dependency needs have no access to any activities. Our expert by experience stated: “In contrast to the managers’ statement about involvement in activities, all residents I spoke to identified daily activities as something that would improve their quality of life. Activities of interest to the residents I spoke to included; needlecraft, bingo, gardening, walking and reading. A particular concern was the lack of physical activity offered for the more mobile residents”. It is considered appropriate to require the Provider to employ a co-ordinator for an established number of hours a week, to facilitate and engender a socialisation programme. Several residents indicated a degree of boredom, measured with: “I don’t like to take part in activities that are offered.” And “I think a few more social activities could be provided, and some entertainment now and again.” We observed, and the expert by experience commented that “the home had a display about the ‘Olympics over the years’ written out neatly and with pictures created by the manager’s daughter. I felt this may have been an opportunity for the residents to have been involved, sharing their memories and assisting in the process”. It is CSCI’s, and the expert by experience’s opinion that creative ways of providing activities such as adapted equipment for those with disabilities; life story work and seeking individual interests would enhance life at Evergreen House. This would be consistent with a ‘Person Centred Care’ approach rather than a task centred approach. An Anglican service is provided on a monthly basis, and a local Baptist minister is making arrangements for sessions. The Church arranges to pick up people Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 17 from the home with a mini-bus, manned by volunteers. A Roman Catholic priest attends on request, and a Church of England communion is given every fourth Tuesday. No other religious or spiritual needs were presented at this time. Volunteers also take people out on to visits to Trentham Gardens, clubs, pubs, and arranged festive events through the local ‘Holiday at Home’ arrangement. Our inspection of residents’ rooms showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. During the course of the inspection staff were observed to interact with people in a positive and polite manner. The standards of catering offered a satisfactory service, to which people spoken to were complimentary of most aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and suitable choice. A pleasant lunch of meatballs or salad was served during inspection, with other choices available, served in dining rooms adjacent to the lounge areas. The expert by experience enjoyed a meal with residents. We found a basic breakfast available with choices of toast, cereals and eggs. At lunch it was meatballs or salad, to which the cook would accommodate other requirements, at teatime and supper snacks were available, i.e. poached egg or mushrooms on toast, again reiterating that it was flexible to meet needs. Hot and cold beverages, and snacks are available throughout the day. Senior care staff sometimes take up catering duties in the absence of the cook. These duties do not adversely affect care staffing levels. People interviewed confirmed that that the quantity and quality food provided was good and generally well received. “I’ve enjoyed my lunch, although I like home cooking better”, “I like the standards of cooking, and the cooks are nice and helpful”, were two comments made by service users. One person and her daughter visiting, said: “nice but a bit spicy, I like old-fashioned English food, but I get plenty”, a view not substantiated overall. We discussed diversity with the cook, who indicated an awareness in meeting individual needs; there were no special needs at the time. The ‘case tracking’ we did identified nutritional and hydration needs of each individual, and it was seen that fluid balance charts, nutritional screening, weighing and hydration needs were monitored. Individual preferences were recorded in assessment and conveyed to the catering staff, who met with, and discussed their requirements. A ‘white board’ is updated daily to identify meals for the day, although poorly situated in the corridor. We observed that staff offered discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of residents. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 18 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): 16,17 and 18. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service has a complaints policy, which allows people to freely express any concerns. People are protected from abuse and their human rights are promoted. EVIDENCE: We found that residents’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place for example, the complaints procedure. We looked at the complaints policy. There were few complaints, which would be better dealt with through a, ‘record of concerns, complaints and allegations’, to record peoples’ and their families’ concerns in a meaningful and effective manner. From our talks with people who use the service, and staff, it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. All residents had received information on the procedure to complain, including reference to us. This process was evidenced through the Service User Guide, on examination and case tracking and discussion. We identified that there had been two complaints made since the last inspection, Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 19 both dealt with internally to the satisfaction of all involved. Case tracking confirmed the effectiveness of a Provider, Care Manager and staff sensitive to people’s needs, and a readiness to test the robustness of their information and report structures. We found the policy and procedure for handling issues of abuse (safeguarding) was examined, and found to be effective, although in need of review to encompass change and past experience. Our previous recommendation to strengthen the staff induction programme, and in-house training was acknowledged, seen to clarify the responsibilities of all staff in their daily contact with residents. We examined staff records to confirm that all staff were suitably checked through Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks. Staff receive training on abuse at induction and there is also a planned programme of internal courses across Choices organisation for more established staff. This includes the right to ‘whistle blowing’ consistent with the Public Disclosure Act 1998. We consider that residents’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place for example, the complaints procedure. The manager had stated in the service’s AQAA submission that: “All service users are provided with a complaints procedure. The complaints procedure is available throughout the home to any one who may require one. All complaints and actions are fully recorded. Policies and procedures regarding safe guarding adults are available to staff and access to external agencies is promoted”. This process was evidenced on examination of records. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 20 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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People live in an environment that is comfortable, clean and allows them to personalise their private space. Some maintenance issues need attention to make the environment safer for the people who use the service. EVIDENCE: We looked around the premises, which we found to be clean, warm and tidy, and that communal rooms and bedrooms were satisfactorily maintained. The garden areas were being maintained at the time of our inspection, being in a satisfactory state for people’s use, with garden furniture and sheds in a good state of repair and secure. Appropriate risk assessments had been made to Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 21 ensure full awareness to safety standards. Attention was brought to our notice over uneven patio floor slabs, which are being maintained that week. A perimeter fencing is satisfactorily maintained, and the front garden and driveway offer a pleasant, well tended introduction to the home. On inspection we found Internal access was facilitated with suitable fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. As we stated previously, on admission the Provider or Care Manager assesses each individual’s needs for equipment and necessary adaptations, all were available throughout the Home. PAT testing was noted as being done on a regular cycle, to meet new situations as they arise, last done on the 13/06/08. Efforts had been made to provide a homely atmosphere and the décor in most areas of home was found to be of a good standard. “The home is nice and quiet compared to some homes, my mum is happy here.” The home provides two lounge areas and a conservatory, that were pleasantly decorated, providing essential furnishings and items to provide comfortable areas where people were able to interact, or to entertain their guests. One lounge had a caged parakeet, that had been risk assessed. A compact, homely dining area was clean and conducive to enjoy a good meal. We found that toilets were located on both floors, in close proximity to bedrooms and communal areas. Two of the toilets are earmarked for renovation this year, although all were presented clean and well equipped. Our observations noted a bathroom on the first floor to have poor décor and flooring, although notified that it is to be refurbished this year. The other bathrooms were satisfactorily presented with good décor and floral displays, but no locks or engaged signs, just a ‘please knock’ sign. The manager is requested to improve on this modification. Water temp was found to be within acceptable limits at 38 c, although there was no bath thermometers readily available, a recommendation for action. Throughout our inspection bedrooms were found to be well maintained to meet people’s personal preferences, with most bedrooms being highly personalised, some displaying their own furniture, and most with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration, as confirmed during the Inspection. Double bedrooms are of a good size but lack the privacy offered by tracked curtains. Portable screens are in use, and considered to be a high risk to injury. It is recommended that these items be resolved as soon as is practicable. Some ‘Tallboy’ cabinet furniture items were in need of securing, as they are inherently unstable. A locked facility is available in some bedrooms, in the style of a ‘money box’, which needs securing. We found the locking mechanism to each bedroom door did not facilitate effective dementia care needs, or allow privacy with easy escape option. The care manager indicated that new doors were on order and that appropriate locks would be fitted. An effective call system was tested; Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 22 care staff reacted promptly. The care manager expressed a willingness to meet any reasonable demand for special needs. We found the heating and ventilation to be satisfactory, and lighting was domestic in style. Fire equipment was inspected, and seen to be serviced and up to date. Those people we spoke to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. Numerous floral displays enhance the presentation. A comment from the assessor stated: “The home was pleasantly decorated and the communal bathrooms had small details such as candles and flowers that added to a comfortable setting. The bedrooms were individually decorated in a variety of colours that residents are encouraged to choose for themselves. Residents are able to display their family photographs and have familiar items of importance to them in their rooms. This was all very positive and for those who have dementia essential to their wellbeing.” We inspected the kitchen, and found it to present a well equipped and organised area. A recent Environmental Health inspection had identified a number of issues associated with data and record management in the kitchen, and the replacement of a poorly functioning fridge. All their requirements were seen to have been complied with. All but one of the fridges and freezers were well maintained and checked daily by the kitchen staff. The kitchen was clean and considered secure, with a cleaning schedule in place. The laundry was well organised, equipped to a good standard, with safety notices regarding detergent handling, in place. We noted that the room was unlocked, presenting a potential hazard. People’s belongings were seen to be handled piecemeal in an organised process, with no evidence of communal usage. Disposable gloves and aprons were seen in use, and liquid soap and paper towels were evident throughout. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. The Registered Provider is to provide CSCI with a development plan for 2008/09, with consideration given to a full risk assessment of the Home. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 23 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): 27,28,29 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service, and on the examination of staff files, working rotas and discussions with staff. Staffing levels ensure that adequate staff are provided to meet the needs of people who use the service. Recruitment, training and supervision processes are consistent, protecting the people who use the service from harm and abuse. EVIDENCE: There were 27 service users in the home on the day of the inspection. We asked for staffing rotas, which were provided and examined; staffing levels were seen to be satisfactory. The daily care staffing rota showed balance between skills, experience and numbers to provide a good standard of care. Our discussions with staff also confirmed their commitment to providing a quality service, and their awareness of the principles of good practice and Code of conduct. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 24 The overall staffing establishments were examined and found to be satisfactory in meeting recognised staffing levels. An average coverage was seen to be: From 26/05/08 – 22/06/08 Morning – Afternoon – Night 1 Senior 3 carers 1 Senior 3 carers 1 Senior 1 carer ( 1 up to 01:00) Our examination of records showed that there are 70 hours/week housekeeping/laundry staffing hours, sufficient to meeting present and future conditions. The home presents a very clean and odour free environment. We acknowledged 76.5 hours for catering staff, sometimes supported by the care manager in times of shortage. A maintenance man works 40 hours a week. Our observations of staff on duty conveyed a positive impression of their competence, and care of service users of the home. We interviewed two members of staff, who confirmed the appropriate staffing levels, conduct and training of staff. Those spoken with on the day of inspection showed satisfactory standards, and an enthusiasm for their work. We examined three staff files, which showed consistency of general application of procedure in appointing staff. The procedures for recruiting and appointing staff were seen to be satisfactorily check listed. Staff had sufficient evidence of clearance with references, and contracts, with thorough checks are made of CRB and POVA records. We consider that the process would be enhanced with interview notes and a letter of appointment. An up to date photograph is recommended for inclusion in all staff files. Staff training was discussed and was found to have been improved in meeting regular and compulsory training needs. Eleven staff have National Vocational Qualification (NVQ) level II, and the Care Manager undertaking level III, with five planned to undertake NVQ training. We acknowledged seven staff with a suitable First Aid Certificate, training completed on the 24/02/06. Induction was seen to be consistent and comprehensive, its effectiveness demonstrated on examining new staff records. A training programme arranged for 2008/09 has not been arranged, and is recommended to be an established management routine. There was evidence to show that a formal supervision process has been introduced, although the process is determined with the single control from the Care Manager, undertaking all staff. The process is thorough and consistent, but requires delegation to ensure continuity. Staff meetings have not been regularised, but performed on a needs must basis, we recommend formalising on a monthly interval. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 25 Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 26 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): 31,32,33,34,45,56,57 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that the home is run in their interests. The service generally promotes the health, safety and welfare of people, but needs some further reviews of some documentation and procedures. The care team promote the health, safety and welfare of people using the service, and working practices are safe. The ethos of the home is based on openness and respect. EVIDENCE: Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 27 The Registered Care Manager Gail Ghadially, has demonstrated a long-term commitment and competence in running Evergreen House over the past eleven years, in establishing a solid foundation to achieve a good standard of set aims and objectives. A qualified general nurse with an extensive practical and managerial experience, representing a clear focal point of control on all aspects of service throughout, with a reluctance to delegate to care staff. We considered that this has generated a ‘task orientated’ system of organisation, reliant upon personal interaction and influence. Nevertheless we were impressed by the openness and confidence in the observed interactions of staff, relatives and residents, based upon mutual trust and respect. The last inspection presented a substantial challenge for the manager to reflect on procedure and practice. We acknowledge the efforts and positive outcomes resulting from a pragmatic, and diligent approach to ensure all the requirements, and most of the recommendations were addressed satisfactorily. Extensive and appropriate risk assessments have been reassessed and are in place for service users, through sound care planning, staff selection and to the general environment, these are up to date and accurate. Health and safety notices can be seen throughout the home, some in inappropriate places, which would be better sited in discrete positions, yet be clearly available to staff. The manager was advised to undertake a home-wide room risk assessment to facilitate effective awareness to risk and developments. CSCI raised the issue of pets at the last inspection, and agreed that there was no objection to a reasonable presence of pets that have been suitably risk assessed, having acknowledged the comments made by several people: “I am very disappointed that the dogs are no longer allowed to be here. Having them here made the home more normal and not as if Dad’s in care.”, and a mother and daughter who said “It was always nice to see a little dog running about, made it a family atmosphere”. One person was however more cautious, who had never had pets and “dislikes dogs”. The general feeling regarding pets was one of acceptance and pleasure of their company. CSCI were informed that the Registered Providers have a high profile and involvement in the smooth running of the Home, and are prepared to delegate a wide range of management responsibility to good effect. We acknowledge that the Provider with the Care Manager, have developed a formal approach to monitoring quality across a wide range of activities. This includes a care plan review process that is recorded at least once a month, a staff training and supervision commitment, and audits of financial and organisational services. Social Workers’ review meetings were seen to offer a vehicle for assessing quality. As we previously mentioned, there is a willingness to create an induction and training environment, with a staff supervision policy and procedure in place, with care staff receiving six sessions of individual formal supervision annually. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 28 We consider that there is a pressing need to establish delegated, cascading programmes as established management/training process. We have recognised that the management had said within the AQAA that: “We feel that, although paperwork is essential and required by law, the actual care that we provide is of more importance.” Nevertheless an examination of administrative, monitoring, planning and care records showed a diligent attitude to effective record keeping, although a level of compensation is made to manage poor levels of literacy skills of some senior care staff. We accessed random samples of records, which were found to be well maintained, accurate and up to date, helping to ensure that the people’s’ rights and best interests are safeguarded. Records inspected included, fire prevention tests on equipment, six monthly fire training and procedures, Health and Safety checks on equipment servicing and planned preventative maintenance and risk assessments. Water record of testing, servicing of hoists, and gas appliances. We examined the procedures manual, and found it to offer a comprehensive reference, up to date, but lacking an index for clear access to specific policies. The Manager offered to us evidence of safe working practices including: Movement and handling training, fire safety training, disposal of waste and handling abuse. Training on infection control is also undertaken, and the policies and procedures for this subject are working documents and regular training in the home. Questionnaires were sent out in February 2008 and the results made available to CSCI, which indicated a valuable exercise, to be repeated each 12 months. We cross referenced the accident record with monitored care records, which were found to be in order for staff, residents and reporting arrangements to Riddor. A three monthly analysis is recorded on trends and frequency. Financial records and administrative procedures relating to the handling of monies of three people using the service were inspected, and were found to be well organised and maintained. An annual recorded audit by the Provider was advised. The administration and management of the home is sensitive to the needs of people. Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 29 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 2 2 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 3 3 3 2 2 Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 30 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 OP1 Regulati on 4 (2) 5 1 (f) Requirement The Statement of Purpose and Service User Guide be kept up to date with CSCI and essential contact information, and be available on request by residents, and any representative of a resident. The Registered person shall make suitable arrangements to ensure that the home is conducted in a manner to respect the privacy and dignity of service users, in the provision of privacy locks on toilets and bathrooms, and tracked curtains in double bedrooms. Timescale for action 01/08/08 2 OP10.1 12 4 (a) 01/08/08 3 OP12 16 2 (n) Review and develop the range of activities and facilities for recreation available to people using the service through the provision of an activity co-ordinator, having regard to the needs of people to recreation and fitness. 01/09/08 Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 31 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 Refer to Standard OP1 Good Practice Recommendations That the Service User Guide is offered in large print and audio versions, and be presented to all residents That the Service User Guide contains information regarding the up to date fees charged. That the contracts offered to residents contain the agreed room number allocated prior to formal admission. Secure a suitable metal; wall (rag) bolted container, for Controlled Drugs, and a suitable CDA register. That Home notices are placed more discretely in residents’ bedrooms, and that names on doors reflect a more dignified recognition. A Concerns, Complaints and Allegation book be established to more effectively monitor incidents. That attention be given in upgrading one upstairs bathroom and two toilets, in accordance to stated objectives within the AQAA submission. To take steps to safeguard residents who wish to use the garden and patio areas, in maintenance of gardens, fencing, and pathways. A development plan be drawn up for 2008/09 That COSHHE laminates be displayed in all areas involving the use of hazardous chemicals, to complement existing procedure sheets. That the recruitment process be enhance with the keeping of interview notes and issuing of a letter of appointment to all new employees, and a staff photograph be placed in the staff file. OP12 OP2.1 OP9 OP10 6 7 OP16 OP19 8 OP19 9 10 OP24 OP26 11 OP29 Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 32 12 OP301 A staff training programme for 2008/09 be forwarded to CSCI as a demonstration of intent in maintaining staff expertise and knowledge. That staff meetings be established on a monthly basis to facilitate effective lines of communication and offer a forum for open and transparent management. That provisions be made to establish a relatives and residents’ forum, to be held at regular intervals. An annual financial audit takes place of the management of residents’ financial dealings by the Registered Provider. Staff supervision be considered on a cascading delegation to senior carers, to ensure continuity of established routines. Bath thermometers be available in all bathrooms to minimise the risk of scalds to residents. Ensure access to all service rooms be secure to casual entry by residents, to minimise risk of injury, i.e. laundry and storage areas. To install a suitable locking mechanism to bedroom doors to facilitate easy escape from room, whilst maintain desired privacy. Remove the portable screens from bedrooms on receipt of tracked curtains, to minimise risk of injury to residents and staff. Ensure that unstable furniture be secured to minimise the risk of injury to residents and staff, i.e. loose mirrors and tallboy furniture. 13 OP32.4 14 15 16 OP33.7 OP34.5 OP36 17 18 OP38 OP38 19 OP38 20 OP38 21 OP38 Evergreen House DS0000004939.V363930.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V363930.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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