Inspection on 26/06/06 for Evergreen House

This inspection was carried out on 26th June 2006.

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

The inspector 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 11/01/08

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

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Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Evergreen House Lichfield Road Tamworth Staffordshire B79 7SF Lead Inspector Mrs Wendy Grainger Key Unannounced Inspection 26 June 2006 10:00 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.V301339.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.V301339.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.V301339.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 8th November 2005 Date of last inspection Brief Description of the Service: Evergreen is a registered home to accommodate 28 older people. Bedrooms are located on two floors, the first floor can be accessed via the shaft lift or stairs. On the second floor are administration offices, which are not accessed by the service users. The home has six double and 16 single bedrooms; there are no en-suite facilities. Located on the edge of Tamworth the home can be accessed via the public transport route. The home stands in its own grounds, there is a small garden at the rear of the home. There is a conservatory at the rear of the home; it has been re furbished and decorated. This was to be used as the new dining room, but the service users preferred it as a lounge. The results of the refurbishment were very tasteful; service users will be protected from the sun with blinds and delicately draped curtains. Management and staff can offer care to meet the varied needs of the service users. Information contained in the pre inspection questionnaire identified that the current fees for accommodation at Evergreen were £350 -£405 per week. Additional costs included hairdressing £5.50 set cut £7.00 perm £18 and private chiropody £16. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed on the 26 June 2006. The registered care manager had provided comprehensive information in the pre inspection questionnaire, resident, relative and other professional agencies had been invited to offer their opinion of the home and care provided. Documentation continued to develop with new ideas being brought into the concept of the daily routine and care records. Residents were spoken with during the day, staff were observed to meet the daily needs of individuals. A tour of the home and a random sample of the bedrooms was part of the inspection. There had been a distinct commitment by the staff and management for the training to offer the appropriate care and stimulation for residents that had a dementing condition; this was obvious from speaking to management and staff and from the stimulation aids displayed. What the service does well: There was a relaxed atmosphere within the home during the inspection, staff and residents moved freely about the home. Staff had a routine for the residents that required more personal care over the day. One resident who was aware that it was time for her change and freshen up confirmed this. The daily menus provided a balanced diet for the residents, special needs for a residents dietary requirements could be provided. The home was maintained to a good standard of hygiene within the areas seen on the day of the inspection. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 7 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.V301339.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including documents provided. The documents provided ensured that a prospective residents and or their family could make a choice regarding a placement. EVIDENCE: The Statement of Purpose remained unchanged; it contained the precise information for a person to make a choice. The document identified that the registered care manger within a twenty-mile radius would make assessments of an individuals needs personally. The most recent placement lived over the twenty mile radius, the inspector was satisfied that the manager had spoken to all the relevant people involved in the care of the new resident; and obtained a number of reports to support the placement. A trial period for this person and any other person was the homes policy. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 9 The registered care manager was in the process of updating the homes policies and procedures. These documents were presented in a very professional manner and available to the staff. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including observations of the staffs working practice and relevant documents. The care plans and reports continued to be further developed by the manager. They were structured and informative. Arrangements were in place for the continued care for the health by other professional agencies. The medication system observed was satisfactory. Staff continued with their daily routine of meeting the care of individuals, they were competent and caring in their approach. EVIDENCE: The formally structured care plans continued to be developed including the new record for the night staff to complete. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 11 The inspector was impressed with the document used by staff for the admission to hospital; this was contained within the care plan. The care plans seen at the time of the inspection were informative and identified all the personal and health needs of the individuals. Arrangements were in place for the continued care of all the residents when applicable. At the time of this inspection four people were receiving full care with additional support from the district nurses. The medication system was satisfactory the appropriate training for the more senior staff and manager had been completed. Staff during the inspection identified a problem with the medication, contacted the pharmacist and made arrangements to amend the problem. Staff were observed during their shift, they demonstrated their ability to care for the resident group. Each resident spoken with was complementary about the care they received from the staff. Staff training was current this included training for the care of residents with dementia, which was on going. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome is good. This judgement has been made using available evidence including speaking with residents and from the records provided. The management and staff continued to provide activities and to encourage the residents to partake. Links with the community and families were maintained. The menus offered a balanced diet, providing choice on a daily basis. EVIDENCE: The residents again were offered an opportunity to attend “Holiday at Home” from one of the local churches this includes outings, teas and a transport service transport was arranged by the volunteers. The inspector was told and one resident confirmed that the home had had a service the previous day. There was photographic evidence of external entertainers providing music and songs; residents were evidenced to join in. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 13 Staff spend time with residents to stimulate them; displayed within the home were hand painted posters that all the residents could enjoy. One of the administrators was responsible for the artwork including a striking painted barometer to indicate the weather. Residents were complimentary about the lunch served, one resident was observed to have breakfast at the time she came into the dining room. This new resident was still settling in and had had a lie in; confirming that residents had choice. Visiting was at any time for relatives, this was observed during the inspection two separate relative were asked their opinion. Each were satisfied that their relative was happy and that they received good care. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using the available evidence including observing documents and speaking to residents. The very detailed larger print complaint procedure was displayed and provided any person with the necessary information. Staff had received various training sessions including their induction for the observation and addressing any potential abuse. EVIDENCE: Residents spoken with were aware of the person to speak to in the event they had a complaint. They were aware of the position of the care manager. Each member of the staff group had received induction training, the staff at the time of the inspection were undertaking dementia training to enable them in their caring. Training needs was part of the supervision provision. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26, Quality in this outcome area is good. This judgement has been made using available evidence including a sample tour of the home. The home was warm and comfortable the ongoing decorating continued to improve the homely environment for the residents. EVIDENCE: The home employed a maintenance person that addressed issues within his remit. There was a need for the review of the nurse call systems on a regular basis when one was identified as not working; others were tested and found satisfactory. The on going decoration was pleasant and fresh with pale pastel colours. The pre inspection and tour of the home identified that a number of areas had been refurbished and items replaced. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 16 There were plans to remove part of the slabs at the rear of the home to provide a gravel area for pots of flowers. Located on the periphery of the town of Tamworth the home is registered to offer care to the older person. Residents spoken with were satisfied with their particular private space, personal possessions were evidenced in bedrooms. The home was maintained in a pleasant odour free style. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including an inspection of staff documents. There were sufficient competent staff on duty to meet the needs of the residents. Staff were trained to provide good care meeting, the personal needs of individuals. Some areas of the records for the recruitment of staff were incomplete. The existing records maintained do protect residents. EVIDENCE: There had been a large commitment to the training both obligatory and external since the previous inspection. More obligatory training and NVQ in Care was planned for July 2006. The manager was aware of the required police clearance on new employees, these were available for inspection. Schedule 2 in respect of photographs and formal identification were not on file. The long standing staff were employed by the previous provider and in some cases did not have written references. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 18 Staff were observed to meet the needs of the residents in a social, pleasant manner while assisting them in their daily routine. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including speaking to the residents and from records. Residents were protected by the commitment of the staff to their safety. The home had a methodical approach to the required records. EVIDENCE: The manager provided two moving letters from relatives praising the staff for their care of their relative. The home operated to the best interest of the residents. They were protected on a daily basis to the best of the staff abilities. Staff and manager confirmed to the inspector that on occasions the more formal supervision of staff was not as regular as planned. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 20 The manager is creating a book, which will include appraisals, supervision, induction, and training records. A random sample of funds held for residents was checked and found to be accurate. The management maintained current records in respect of fire protection, and prevention. The home was aware of the pending new legislation for fire. Other tests to protect the home and residents were current and made available to the inspector. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 21 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 X 3 3 3 Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 22 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. Timescale for action 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP36 Good Practice Recommendations To ensure the planned timescales for staff supervision are adhered too. Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Evergreen House DS0000004939.V301339.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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