Inspection on 05/01/06 for Evergreen Lodge Nursing Home

This inspection was carried out on 5th January 2006.

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 Lodge Nursing Home 01/10/07

Evergreen Lodge Nursing Home 07/08/06

Evergreen Lodge Nursing Home 19/09/05

Evergreen Lodge Nursing Home 04/02/05

Evergreen Lodge Nursing Home 20/09/04

Evergreen Lodge Nursing Home 28/01/04

Evergreen Lodge Nursing Home 15/09/03

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

CARE HOMES FOR OLDER PEOPLE Haddon Nursing Home Haddon Road Rock Ferry Birkenhead Wirral CH42 1NZ Lead Inspector Andrea Morris Unannounced Inspection 5th January 2006 10:30 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 Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 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. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Haddon Nursing Home Address Haddon Road Rock Ferry Birkenhead Wirral CH42 1NZ 0151 643 1068 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) Haddon Nursing Home Ltd Elizabeth Ann Nolan-Davies Care Home 34 Category(ies) of Dementia - over 65 years of age (34) registration, with number of places Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named person under 65 years of age Date of last inspection 19th September 2005 Brief Description of the Service: Haddon House is purpose built care home providing personal care and support for 34 older people with dementia. The home is located in the Rock Ferry area on the Wirral and is easily accessible by public transport. All of the residents’ accommodation is provided in single bedrooms on the ground and first floor of the home. The home has a large sitting room, conservatory and dining room on the ground floor. The home is staffed twentyfour a day by qualified Registered nurses. The home has various aids to promote the residents’ independence and safety such as: grab rails, assisted baths, passenger lifts and hoists. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over 4 hours. During the inspection the inspector spoke to the manager, staff and residents’. A variety of documentation was also examined including staff personnel files, residents care files, financial documentation and certificates relating to Health and Safety. What the service does well: What has improved since the last inspection? What they could do better: Care plans should be reviewed on a monthly basis and amendments documented where necessary. Residents’ with specific needs at night must have a care plan to reflect the care they require. Some decoration is required in the home namely to several rooms where wallpaper is peeling off, and to the link corridor on the ground floor. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 6 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. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 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 Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 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, 2, 3, 4, 5, 6 Residents’ are only admitted to the home following a full assessment of their needs, this ensures the residents’ safety and interests are promoted. EVIDENCE: The statement of Purpose and the Service User Guide contains the relevant information; a copy is available upon request from the manager. Every resident who enters the home is in receipt of a written contract, this clearly identifies the individuals terms and conditions of residency. The Manager or Deputy Manager carries out a pre-admission assessment, this ensures that residents’ needs are met prior to entering the home. Any potential resident who wishes can visit the home. They if they choose can stay for a morning/afternoon or for a meal at no extra cost. The home does not provide intermediate care. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 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, 10, 11 Residents’ care plans must reflect the true care required, reviews of care plans must also be recorded to meet the residents’ changing needs. EVIDENCE: Individual care plans are created for each resident, all aspects of personal, health and social care are included. Four care files were examined and it was found that residents’ care plans were reviewed on a monthly basis, however required changes in care were not recorded in the relevant care plan. A resident with particular night needs also did not have a care plan to support the night care that was being reported as required. There was no evidence in the daily record to support the night requirements of that particular resident. Residents’ are able to choose where and how they spend their day. It was witnessed by the inspector that staff carried out care ensuring the residents’ dignity and privacy was maintained. The homes’ policy relating to care of the dying is appropriate, the manager holds the Certificate in Care of the Dying. Staff receive in house training in care of the dying. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 10 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 Residents are assisted in maintaining contact with the local community and family and friends, this promotes their emotional well-being. EVIDENCE: The daily routines of the home are flexible to ensure the residents are able to choose how they spend their day. Activities are provided on a daily basis. On the day of the inspection several residents’ where going on an outing to the pantomime. Many activities are carried out on an individual basis. Records are maintained of who has participated to monitor appropriate activities. Local churches visit as necessary. The home also arranges for entertainers to visit the home on a regular basis. The home operates an open visiting policy, residents’ can receive their visitors in the privacy of their own rooms if they wish. The home holds residents’/relatives meetings on a bi-monthly basis. The homes menus operate over a four weekly cycle. Options are available and every effort individual preferences are accommodated. The kitchen was found to be maintained to a good standard and well managed. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 11 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, 17, 18 The home has an adequate complaints policy.. Complaints are taken seriously as appropriate action taken EVIDENCE: The complaints procedure is displayed in the entrance area of the home; it is clearly written and gives details on how to contact the Commission for Social Care Inspection if required. All complaints received in the home are documented along with the outcome. The home does not hold power of Attorney for any resident. Families are encouraged to manage their residents’ accounts, where there is no one available an advocacy agency will be contacted so to ensure the residents’ finances are protected. Any resident who wishes to vote can do so through the postal voting system, or if they prefer staff will assist them to the local polling station. The home has an adequate adult protection policy all staff receive training on adult protection during the induction period and again through a rolling training programme. This training is carried out in house for all staff members. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 12 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, 22, 23, 24, 25, 26 The home must maintain an on going re-decoration programme to ensure the environment is safe and comfortable for all residents’. EVIDENCE: There is an on going re-decoration programme, there are several rooms that were identified to the manager during the tour of the home that require redecoration due to the wallpaper being damaged. The link corridor décor is damaged and needs to be addressed so to ensure the environment remains pleasant. There are sufficient bathrooms and showers in the home, these are well maintained. The home has access to special equipment such as hoists and air mattresses. These are services on a regular basis. Many residents’ rooms were viewed, all were found to have personal effects which assists in orientating residents’ to their environment. The home is clean and free for any unpleasant odours, some furniture has been replaced as required in the previous inspection. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 13 Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 14 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 The procedure for recruitment is satisfactory and promotes residents’ are safety and protection. EVIDENCE: Following a requirement from the previous inspection the home has increased the staffing levels on the morning shift to better meet the needs of the residents’. A selection of personnel files was examined; a robust policy for recruitment is being followed, all files seen contained the necessary information. It was evident that staff are being screened prior to commencing employment so to safeguard the residents’. The majority of staff have received training in Dementia Care and Challenging Behaviour. The manager is committed to training, most training is delivered in house but sources outside the home are also accessed where appropriate. 52 care staff have completed NVQ2 or above in care. There are currently a further 8 due to complete in 2006. It was noted during the tour of the home that the staff had a good rapport with the residents’. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 15 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, 34, 35, 36, 37, 38 The home is well managed, thus promoting high standards of care for residents’. EVIDENCE: The manager is registered with the Commission for Social Care Inspection. The manager has completed a variety of courses and is due to complete her degree in Elderly Care summer 2006. Staff who spoke with the inspector stated that the manager was approachable and fair. They stated they had confidence in her leadership. The home has maintained the ISO 9000 quality assurance. The home internally monitors daily practices to ensure the best interests of the residents’ are maintained. The manager carries out supervision of staff, the manager must ensure all care staff receive at least 6 supervision sessions per year. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 16 The finances that are held in the home were examined. Records are kept of residents’ individual allowances however, the current system appears confusing, a clearer system of recording input and output of monies must be identified in order to protect all residents’ from financial irregularity. The certificates relating to Health and Safety were examined, all were found to be in date and valid. The manager carries out internal risk assessments relating to the building on a regular basis. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 17 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 3 3 3 N/a N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 N/a 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 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 3 N/a N/a 3 3 3 3 3 Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 2 3 Standard OP7 OP7 OP19 Regulation 15(2)(b) 15(1) 23(2)(b) Requirement The registered person shall ensure care plans are kept under review. The registered person shall ensure all residents have care plans relevant to their needs. The registered person shall ensure the premises are kept in good state of repair externally and internally Timescale for action 31/01/06 31/01/06 30/04/06 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 OP34 Good Practice Recommendations It is recommended that the system for recording residents’ money is reviewed to clear identify what is currently being held in the home. Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Haddon Nursing Home DS0000034955.V277172.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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