Inspection on 08/11/05 for Evergreen House

This inspection was carried out on 8th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 29/06/05

Evergreen House 02/11/04

Evergreen House 27/07/04

Evergreen House 07/03/04

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Heathlands

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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 Unannounced Inspection 8th November 2005 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.V262304.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 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.V262304.R01.S.doc Version 5.0 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 29th June 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 and 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. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 8th November 2005 by one inspector. The management, residents and staff who provided comments and information assisted the inspector. Documents, records and reports were made available. No formal comment cards had been received for this unannounced inspection. Residents commented informally to the inspector that they were satisfied with the home the care and food they were served with. During the inspection a small group of residents took the opportunity to personally make Christmas cards. During discussions with a group of residents in the conservatory it was suggested that a more formal residents meeting may be useful to feed back ideas and comments about their life style and interests. The registered care manager does an informal get together. The registered care manager continued to complete full assessments of an individuals needs prior to admission. The format of the care plans remained the same, there had been a major change in the recording of daily observations, this style if used effectively could prove to be informative. Arrangements were in place for the continued care of residents via other professional agencies; this was evidenced from the sample of care plans. The system for medication was in general, satisfactory. The registered care manager delegated the checking for the administration of medicines to the senior staff. Staff responsible had received the appropriate training for the safe handling of medicines. The menus provided and meal observed during the inspection were balanced and provided a choice of meals. The cook was aware of the likes and dislikes of certain residents and provided the appropriate meal. A sample tour of the home identified that the home in general was well maintained the provider continued to upgrade and refurbish the home and had a rolling programme for decorating. New flooring was being fitted in some bedrooms. A small number of wardrobes that were not secured to the wall in order to prevent them toppling over needed fixing to the wall, the carpet on the first floor landing is a potential hazard and required attention. The home had systems in place that ensured the safety of the residents when employing any new staff. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 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.V262304.R01.S.doc Version 5.0 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 Standard six is not applicable to Evergreen. The documentation provided would ensure that the relevant information about Evergreen and staff was current. The assessment of needs continued ensuring individuals needs could be met. EVIDENCE: The Statement of Purpose and Service Users Guide remained unchanged these documents were available to any person visiting or resident at the home. The registered care manager continued to complete assessments prior to admission. The senior staff followed the admission policy if they were responsible for an admission. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 9 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 Aspects of individuals personal and health needs were identified in the plan of care. Residents could expect their health needs to be addressed or referred to other agencies if necessary. The system for the medication was in general satisfactory. The system for checking medicines administration needs to be monitored as some omissions were noted. EVIDENCE: A sample of care plans were seen, the resident’s needs had been identified, residents confirmed that they were comfortable and well cared for. One resident told the inspector that she preferred to spend her time in bed. Following the last inspection the registered care manager had introduced a new daily reporting system. If used appropriately it could be informative, identifying that daily needs had been addressed. Arrangements were evidenced when the District Nurse visiting the home addressed the needs of individuals. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 10 The inspector was concerned in respect of the condition of a number of walking frames where ferrules were worn and in one case one resident was walking with one ferrule detached. This was discussed with the registered care manager and recommended that monthly checks should coincide with the checks on wheelchairs. There had been an area of concern in respect of medication; the registered care manager had delegated the checking of medication to the senior staff, there was a need to monitor the signing when a small number (5) had not been signed for. In general the system of checking was working. Staffs on duty were responsive to the needs of individuals, they were experienced and knowledgeable about the home and the residents they care for. Residents were relaxed with the staff. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 11 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): 12,13,15 Links with families and the community were maintained. The menus and meal seen on the day was nutritious and balanced offering choice daily. EVIDENCE: The residents at Evergreen maintained contacts with their families and links to groups in the community. Special seasonal events were celebrated, an entertainer was arranged for the Christmas party and carol service late in December. During the inspection a small number of residents choose to colour some pretty Christmas cards for families. The meal of the day was seen, the portions were ample to suit individual choice. The meal was served from a trolley to residents. Alternatives were prepared where appropriate; one resident preferred not to have any type of sauce (parsley) and was served fish in an alternative form. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 12 The pudding was a home cooked chocolate pudding with custard. Home cooking was a priority for the cooks where ever possible. It was pleasing to observe that the vegetables were prepared on the day, ensuring they were fresh. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 13 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 The homes complaint procedure enabled any person to raise concerns through the appropriate channels. Staff training ensured that the staff were aware of the need to monitor care practices for any form of abuse. EVIDENCE: The Commission had received one complaint; this had been investigated internally by the registered care manager and the respective people written too. The home displayed the appropriate complaints procedure for reference. Residents were protected from abuse via the training and experience of the staff in the caring profession. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 14 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 22 23 24 25 26 The home was warm and comfortable; residents had options of where to relax. There were potential hazards for residents and staff identified within the building. EVIDENCE: Located near to the town of Tamworth the home is suited for its intended purposes. The provider continued with the systematic upgrading and refurbishment of the home. Evidenced was the non-slip vinyl flooring to be fitted in certain bedrooms. During the tour of the home it was identified that the carpet on the first floor landing was a potential hazard and required re-stretching. Following the decoration of bedrooms and including the wardrobe on the ground floor were unsecured. It was required that this is addressed. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 15 Residents were encouraged to bring in personal possessions for their bedrooms. The roof on the conservatory had been painted to protect the residents in the summer months; this coating now needs to be removed allowing more natural light to penetrate. Good standards of hygiene were observed throughout the home, which was warm and comfortable. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 16 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): 27,28,30 The levels of staff were deemed to be acceptable for the numbers and dependency of the present residents. There was a requirement for staff to have current obligatory training. Appropriate staff training for the care of older people was excellent. EVIDENCE: Senior carers supported the registered care manager; one was on duty for each rostered shift. At any one time during the day there were sufficient staff on duty. Some staff chose to complete a long shift (8am-8pm) Catering and housekeeping plus maintenance were part of the staff team. The obligatory training was evidenced with the exception of First Aid, which was not current for a number of staff. The registered care manager had the extended training lasting three years. External NVQ training continued, all the staff employed had either NVQ II or NVQ III in care, the registered care manager with the administrator had almost completed level III in care. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 17 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 33,36,38 The provider and registered care manager promoted the safety and security of the residents as far as practicable A more formal structured residents meeting should be considered and recorded in the form of minutes. The home had good systems in place for the protection of residents in respect of fire and training. EVIDENCE: The registered care manager who had many years experience in the care of older people operated the home. She had awareness of the aging process and maintained her knowledge with various training sessions. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 18 The registered care manager told the inspector that informal discussions were part of the resident feedback for the service provided. It was felt by a couple of the residents that a more formal meeting would be useful. This was passed onto the registered care manager. The records for the regular testing of the fire system and training were current and well maintained. Staff during the inspection confirmed that they had regular supervision sessions with the registered care manager. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 19 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 2 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 X 18 3 2 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X X 3 3 3 Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 20 Yes 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 OP8 Regulation 13 4 (c) Requirement Timescale for action 21/11/05 2. OP19 13 4 (a) 3. OP30 13 4 The registered person shall ensure that unnecessary risks to the safety of residents are so far as possible eliminated. The registered person shall 21/11/05 ensure that all parts of the home that residents had access to are so far as practicable free from hazards. The wardrobes needed securing to the wall. The registered person shall make 21/11/05 suitable arrangements for the training of staff in first aid. 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. Refer to Standard OP9 OP19 Good Practice Recommendations For the staff to monitor the record for the administration of medicines and ensure they are appropriately signed for. To remove the whitening from the conservatory roof to allow more natural light. DS0000004939.V262304.R01.S.doc Version 5.0 Page 21 Evergreen House 3. OP33 To consider a more formal style of obtaining residents views by holding and recording residents meetings. Evergreen House DS0000004939.V262304.R01.S.doc Version 5.0 Page 22 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. 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