Inspection on 29/06/05 for Evergreen House

This inspection was carried out on 29th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 26/06/06

Evergreen House 08/11/05

Evergreen House 02/11/04

Evergreen House 27/07/04

Evergreen House 07/03/04

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

CARE HOMES FOR OLDER PEOPLE Evergreen Lichfield Road Tamworth Staffordshire B79 7SF Lead Inspector Wendy Grainger Announced Wed 29 June 2005 09.00am 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 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 E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Evergreen Address Lichfield Road Tamworth Staffordshire B79 7SF 01827 50675 01827 50120 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Kailash Jayantical Patel Mrs Gail Margaret Ghadially Care Home 28 9 28 9 Category(ies) of DE registration, with number OP of places PD Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) To permit the admission of one gentleman under 65yrs of age. Date of last inspection 2 November 2004 Brief Description of the Service: Evergreen is a registered home to accommodate twenty-eight 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 and not accessed by the service users. The home has six double and sixteen 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 recently 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 Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a period of a day on the 29th June 2005. Prior to the inspection commencing the Commission and Inspector had received five comment cards from residents and three from relatives. Two relatives made additional comment as to their satisfaction in respect of the care provided. One however felt that at times there was a shortage of staff. With the exception of one resident who only liked living at the home sometime, sometimes the person did not like the food the remaining comments were positive. One family confirmed that they called three times each week, each time they felt welcome. Their relative confirmed that she had chosen her very colourful socks today. A son of a resident told the inspector that he was very happy with the care his mother received. The inspection methodology was explained to the care manager who with her staff assisted with the inspection by providing the required and extra documents the Commission could retain on file. A new Statement of Purpose had been produced identifying relevant changes. The Inspector was provided with the homes Business plan for 2005. the Care Manager is planning to introduce a new Service Users Guide in an alternative format and to include extra information within a welcome pack. Residents had either retired to their rooms after breakfast or were in the two sitting areas. There was a relaxed atmosphere between the staff and the residents. The future plans for the home were to replace some of the arm chairs for the conservatory. To change carpets within the bedrooms and home and to continue with the decorating programme. Accommodation was located on two floors, they’re continued a decorating programme. The entrance hall and stairs at the front of the home had been decorated. It looked classical with a wine and cream colour scheme. The recently decorated dining room continued the colour scheme, tasteful touches had been added to the dining room. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 6 The home in general was clean and tidy one resident complimented the cleaners, one of the ground floor bedrooms had a slight odour. This bedroom would be on the next decorating and carpet changing programme. The inspector was told that the carpets were cleaned on a regular basis. It is important that regular checks were carried out on the residents call system. And that residents could access them easily without the use of the extension cord. One call system was found not to be working; this was rectified during the inspection of the room when the connection was identified to be faulty. A concern identified during the inspection was that a fire door was held open by a table. The resident in this bedroom on the ground floor told the inspector that she would be unable to breath if the door were closed. The resident chooses to remain her room. The provider must address this non-compliance with the fire requirements as soon as possible. Devices are available to close the door in the event of a fire, the fire officer should consulted on its oppropriatenese. The inspector was concerned that the staff continued to use a Latex protective glove; the reason for the non use of this equipment was explained and the alternative in the form of a risk assessment should be conducted on each resident and staff in the home; if the product was to be used. The Care Manger was not aware of the withdrawal of Latex gloves; her supplier continued to provide them without providing her with up to date information. The home continued to comply with the policies and procedures for the Choice of Home with full assessments prior to admission. Arrangements were in place for meeting the health, personal care and social needs of individuals. The dependency levels at the home had decreased; two of the residents were in hospital at the time of the inspection both expected home soon. The inspector was impressed with the detailed colourful information provided for all to see in respect off the pending “heat wave” and what to do in the event any person is ill. Observations of the food being prepared and served were that the home provided a choice of a balanced and nutritious diet. Special diets were catered for as required. The inspector was served with a varied salad, presented in an attractive manner. Evergreen residents were always served with a cup of tea after lunch. This further ensures that fluid levels were promoted. The majority of the staff had some NVQ qualification and further training was planned for NVQ. The Care Manager, a qualified nurse continued with NVQ in Care level III alongside her staff. Staffs at the home were competent to care for older people. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 7 Recruitment had recently included staff from abroad. The inspector was impressed with the paperwork for employment and Criminal Records Bureau checks and POVA. What the service does well: What has improved since the last inspection? What they could do better: The decorating programme needs to continue, plans to replace furniture in bedrooms would benefit the homely environment. This inspection had identified requirements namely:1.To ensure that fire doors were not wedged open. 2.To ensure that the staff were aware of the need to concentrate when administering medication and not to allow any distractions. 3.To complete a risk assessment for cot sides and to ensure that the metal cot side remained covered at all times. 4.Take measures to remove the slight odour from one of the ground floor bedrooms. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 8 Four recommendations were identified namely:1. To discontinue the use of Latex gloves or to risk assess as discussed. 2. To store oxygen in a stand or remove the cylinder to the store when not required. 3. To check the residents call system on a regular basis to ensure it works. 4. To monitor the environment where necessary for any odours. 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 E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5. Standard 6 is not applicable to Evergreen. Management provided detailed information in respect of the home to assist any person with a placement. From the documents made available the person could make an informed choice. A new Statement of Purpose has been developed. Positive assessments were operational before residents came to the home. EVIDENCE: The Statement of Purpose and the Service Users Guide were in place, and provided the relevant required information about the home and its facilities. Each resident would be provided with a contract, this might be from the home or from the placing agency. Individual assessments prior to admission or re admission following a hospital stay were part of the commitment of care by the home. A trial period was part of the contract and reviewed when applicable. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 There was a clear consistent care planning system in place that identified individuals needs. Appropriate arrangements were in place for meeting the health needs of residents. The system for administering medication was satisfactory if followed as part of the policy for the home and via the provided training. However in practise on the day of inspection was found to be not up to standard with errors being identified. The staff were respectful, helpful and assisted residents, protecting their dignity. EVIDENCE: A sample of care plans were evidenced including the respite care person, the only comment would be that for the respite person a secondary contact number would have been useful. Within the plans was a document that staff used as a check when admitting someone to the home from the welcome to settling the person in with drink. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 12 The risk assessments were in place where necessary. Arrangements were in place for the continuing health care of individuals. Records evidenced contacts with general practitioners and other health carers. The use of Latex gloves was discussed with the Care Manager and the procedures that must be completed if the home continued to use the equipment. The dangers of Latex allergys were explained. There was a need for the cot sides provided to be covered to protect the resident and to comply with Health & Safety. The senior staff contacted one of the surgeries that had provided the cot sides to be informed that they do not advocate the supply of sides, as a crash mattress should now be provided. The inspector discussed concerns following the inspection of the medication. The staff in charge when medication was received checked and signed a form. The person that admitted the respite person failed to recognise that some medication was different; with four ten mg for two days and one 40mg for the rest of the week. The medication had been dispensed into a wallet by his carer. Extra medication was found in an envelope in the wallet. The resident confirmed that he had this medication occasionally. There was no evidence of this medication being recorded on the MAR sheet. There was no written evidence by the senior staff in respect of the administration of this alternative medication. On two different occasions staff had signed for medication and not administered it. This was part of the feedback and would result in a requirement being made for the staff to be more vigilant. These errors had occurred despite staff receiving training. An oxygen cylinder was identified in the smaller lounge, the Care Manager removed it during the inspection. The resident prescribed for this medication intermittently required oxygen used when an attack occurred. Residents who were able to offer an opinion said they were well treated, their dignity and privacy was respected. The inspector observed dignity being respected. Staff were sensitive and demonstrated their commitment to caring. The home had the appropriate policies for death and dying, the inspector was impressed with the detailed information obtained by the care manager for relatives following their relative passing away. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12 ,13,14,15 Residents were offered choice within their capabilities and daily routine. There was a relaxed atmosphere in the home and between the staff. The meals provided offered choice from a balanced menu. EVIDENCE: Residents were wandering freely around the home during the inspection. Some chose to remain in their bedrooms. The comments from residents spoken with were positive, confirming they had chosen some item of clothing that morning. Visitors were welcome in the home at any time this was evidenced during the inspection. One family had arranged to accompany their relative to a hospital appointment. Earlier in the day a member of staff had acted as escort. The annual “holiday at home” where a few residents had enjoyed the week. This was arranged by one of the local churches. The Inspector spent time in the afternoon with residents as they enjoyed musical entertainment. A number of residents that displayed limited interest, were stimulated and motivated enough to join in the singing and dancing. Pictorial records of the VE Day celebrations were shown to the Inspector. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 14 Menus were displayed within the dining room the alternatives offered were identified. The required temperatures checks were made available for fridge and freezers and food served. The kitchen hatch has been reopened since the decoration of the dining room. This will alleviate staff standing in the corridor to assist with meals. The main meal will remain served from the trolley. The quality of food and its presentation was seen to be satisfactory on the day of the visit. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 15 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 standard(s) ,16,18, Information in respect of the complaints procedure was contained in the relevant documents and displayed in the home. The home had the appropriate training in place to protect residentsfrom abuse. EVIDENCE: The complaints process was displayed within the home, and within the relevant required documents. The management in the event of an internal concern maintained records. The staff had received training in how to recognise and deal with any style of abuse. Staff confirmed that they would not hesitate to speak to the appropriate person of Commission. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19 20 21 23 24 25 Evergreen House provided for residents a safe warm environment. There were a few areas that needed to be monitored. The held open fire door could be seen as an area residents would not be protected in the event of a fire. Not every area of the home was odour free. EVIDENCE: The front of the house was colourful with hanging baskets, pots of flowers and white painted stones around the centre area. There was a noticeable odour in one bedroom, the carpet is due to be changed when the room is decorated. The home had a rolling programme for decorating and refurbishing. There were plans to purchase new bedroom furniture and armchairs. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 17 There had been no change in the configuration of the bedrooms. One residents call system was identified as not working; the Care Manager rectified this when it was identified that the fitting was loose. Bathrooms and toilets were appropriately sited around the home. It is hoped that the raised automatic toilet area, which has been out of order for some time can be redesigned into an extra shower room located on the ground floor. Numerous personal possessions were evidenced in bedrooms. The inspector discussed with one resident the need to have her fire door closed at all times unless it was fitted with appropriate device. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The management ensured that the procedures for recruitment were robust. Staff on duty were competent and satisfactory in numbers to meet needs of individuals. The home was committed to staff training complying with the Standards. EVIDENCE: At the time of the inspection there were twenty-three residents at the home with one Care Manger and four staff with catering, housekeeping, maintenance and adminstration. The staffing levels remained the same for the later shift. Some staff chose to work a long day (8am 8pm) the management had bank staff available. The staff were experienced and aware of the needs of the residents. Recruitment had been robust and had included staff from abroad. The inspector was impressed with the paperwork held and checks made for overseas employees. Training was on going, the majority of the staff had a Level II NVQ in Care; further training in NVQ was being undertaken. Mandatory training with the exception of First Aid was current according to the records. This will be arranged in the near future. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36,38. The staff were aware of the philosophy of the home to provide a relaxed homely environment. This was achieved via the management skills. Training was part of the commitment to the residents well-being and staff supervision was in place. EVIDENCE: The registered Care Manger continued with Level III NVQ in Care, she updated her mandatory training as necessary. She leads by example, staff confirmed that they felt they could approach her if necessary. Staff confirmed that they received supervision this was backed up by the completed paperwork. The style of document used did not compromise confidentiality. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 20 The records of the small number of hairdressing and small personal monies were evidenced. A copy of the home insurance details was provided for the Commission. During the inspection the inspector witnessed the weekly fire testing of the system. Staffs were asked questions and signed the records. The gas system was serviced 30 June 2005. The NIC certificate was in date as were passenger lift servicing, PAT testing, Hoists, Emergency lighting and fire alarm servicing. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 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 Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 3 x 2 Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 (2) Requirement the registered person shall ensure that the staff responsible are trained to administer medication, complete the administration and recording as per the policies and procedures for the home. the registered person shall after consultation with fire authority make arrangements for the safe keeping of the residents. Holding open fire doors is not acceptable and an alternative device should be fitted. the registered person shall make suitable arrangements for unnecessary risks to the safety of the resident are so far as possible eliminated. Risk assessement for cot side should be in place for all residents where cot sides are in use.. Timescale for action on going 2. 24 23 16 7 05 3. 38 13 (c) on going RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Evergreen Refer to Good Practice Recommendations E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 23 1. 2. 3. 4. Standard 8 8 24 24 to discontinue the use of Laxex gloves or to complete a full risk assessment on each and every person within the home. to ensure that when the oxygen was required then it is correctly stored in a carrier and identified as to the dangers. to have a regular monitoring of the residnets call system to ensure the working order at all times. to monitor the slight malodours identified in one bedroom. Evergreen E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - 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 E09 E51 S4939 Evergreen V228298 290605 Stage 4.doc Version 1.30 Page 25 - 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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