Inspection on 07/08/06 for Evergreen Lodge Nursing Home

This inspection was carried out on 7th August 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 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 Lodge Nursing Home 01/10/07

Evergreen Lodge Nursing Home 05/01/06

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 09:30 7 & 29th August 2006 th 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.V298586.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. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 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.V298586.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named person under 65 years of age Date of last inspection 5th January 2006 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.V298586.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out unannounced and over two days. During the inspection the inspector examined a selection of documentation including resident care files, medication records, health and safety certificates, training records and financial documentation. The inspector spoke to several residents, staff and the deputy and Home Manager. What the service does well: What has improved since the last inspection? What they could do better: Care plans lack detail and do not always reflect a persons needs. When reviewing care plans changes identified must be recorded on the care plan. Decoration is needed in several bedrooms to ensure a satisfactory standard is maintained. Door frames are in need of repair and decoration to assist in maintaining a homely atmosphere. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 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.V298586.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 Haddon Nursing Home DS0000034955.V298586.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, 2, 3, 4, 5, 6 Residents are only admitted to the home following a full assessment of their needs, this assists in ensuring residents needs can be met. EVIDENCE: The homes statement of purpose and service user guide contains all the necessary information. It is kept under regular review. There have been no changes to it since the last inspection. All residents admitted to the home are in receipt of a written contract that clearly defines their terms and conditions of residency. All residents are assessed prior to entering the home; the home manager or deputy completes the assessments. All potential residents are encouraged to visit the home with their families prior to admission; potential residents are able to arrange to stay for an afternoon or a meal if they choose at no additional cost. The home does not provide intermediate care. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 9 Haddon Nursing Home DS0000034955.V298586.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, 11 Care plans are not formulated to reflect the needs of each resident, risk assessments are not kept under review, thus placing residents at risk of potential harm. EVIDENCE: A selection of care files were examined and found not to be adequate, care plans were formulated for some residents but some care files lacked essential care plans, particularly for prevention of pressure area breakdown. Many care plans were deemed to be vague and describing the care a resident needed. Risk assessments were also created but not all were being followed and on review were not being up dated. Weekly weight charts were noted not be completed correctly, some only being recorded on a monthly basis. The homes medication was checked the Controlled drugs were counted and found to be correct, the fridge temperatures were noted to be recorded on a daily basis. However, the short life medication held in the fridge was found not to have dates of opening documented, handwritten entries did not contain the necessary two signatures as required. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 11 On most drug sheets it was noted that there was several signatures missing for medication that had been distributed. Residents who spoke with the inspector stated they were happy in living in the home, it was noted that staff offered choices to residents and that the staff respected the choices made. The homes policy on care of the dying remains appropriate. Haddon Nursing Home DS0000034955.V298586.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 Meals are well balanced and nutritious, this assists in ensuring residents remain healthy. EVIDENCE: The home is currently awaiting a new Activities organiser to join the team, however care staff provide the residents with opportunities to engage in activities within the home. The home enjoys visits from the community on a weekly basis, an aroma therapist, hairdresser and every Wednesday the Salvation Army visit. The home has recently started to receive visits from P.A.T (Pets as therapy) dogs. The home also has monthly entertainers visiting the home. The home operates an open visiting policy, visitors were seen coming and going freely in the home. Residents during the visit where noted to be able to choose how they spent their day, residents were able to wander freely and spend time in their room if they chose to. A four weekly menu cycle is operated in the home, there is a choice of meal at each sitting. Residents are encouraged to take their meals in the dining area but they can choose to eat in their room if they wish. Residents who spoke with the inspector stated they liked the food provided. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 13 Haddon Nursing Home DS0000034955.V298586.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, 17, 18 Staff receive regular training in adult protection, this assists in protecting residents from potential harm. EVIDENCE: The management of complaints is adequate, the home records complaints received and the action taken in a file. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. All residents on entering the home are placed on the electoral role, residents with the assistance of their families can maintain the right to vote via the postal system, or if they prefer can be assisted to the local polling station. The home does display details of independent advocacy agencies for residents and their families to access independently and in confidence. The majority of the staff have completed the training in adult protection. The remaining staff are due to complete in September 2006. There have been no adult protection issues since the last inspection. The home has a copy of the Wirral No Secrets adult protection policy. Haddon Nursing Home DS0000034955.V298586.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, 22, 23, 24, 25, 26 The home is cleaned to a high standard, this assists in providing residents with a pleasant atmosphere in which to live. EVIDENCE: During the tour it was noted the home is maintained to a reasonable standard, however certain areas require some re-decorating mainly the corridor areas to both floors and particularly the middle corridor by the lift, many door frames are in need of repainting and damaged areas must be repaired. The garden area is well maintained access is via ramps. The home has the use of two types of hoists which staff have received regular training in. All residents’ rooms that were seen were personalised with their own memorabilia, residents are encouraged to bring in items to assist them to settle into the home. The home during the two days of inspection was noted to be very clean and free from any unpleasant odours. A high standard of cleaning was noted. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 16 There are plans for new flooring to be placed down on the ground floor corridors by the beginning of October 2006. Haddon Nursing Home DS0000034955.V298586.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 Staff files are well maintained and staff are appropriately checked, this assists in protecting residents from harm. EVIDENCE: The home has rotas that are appropriately staffed, the home uses very little agency mainly to cover holidays or last minute sickness. Staff receive regular training in all aspects of care. All staff have recently completed moving and handling training and some have also done the fire update training. Training records are maintained well by the home manager. 69 of care staff have completed the NVQ2 in care. Other staff are awaiting to commence on the course in the near future. A selection of staff personnel records were examined all contained the necessary information as required in Schedule 2 of the National Minimum Standards. All staff are checked against the Criminal Records Bureau. All staff are in receipt of their job description this ensures all staff are aware of the roles and responsibilities. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 18 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, 32, 33, 34, 35, 36, 37, 38 The manager is experienced and provides strong leadership to staff, this assists in providing good standards of care to residents. EVIDENCE: The manager is registered with the Commission for Social Care Inspection. The manager has recently completed a degree in Elderly Care. She is experienced in management and provides strong leadership skills to staff. Staff who spoke to the inspector stated they found the manager knowledgeable and fair, she was approachable and provided them with clear guidance. The home is accredited with the Investors in People Award, this is an outside audit agency, the home also carries out internal audits of clinical practice to ensure standards are developed and maintained. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 19 The home has revised its system for recording residents’ finances in the home, a sample of financial documentation was examined and found to be recorded appropriately and monies held correct. Staff receive regular supervision from the manager, records are maintained to a satisfactory level. The home reviews its policies and procedures on a regular basis, to ensure care practices remain safe and up to date. The certificates relating to Health and Safety were checked and all found to be in date and kept under review. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 20 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 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 4 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 15(1) Requirement Timescale for action 25/09/06 2. OP9 13(2) 3. OP19 23(2)(d) The registered person shall ensure a written care plan is formulated that specifies the residents individual needs in respect to his/her health and welfare are to be met. The registered person shall make 25/09/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 1) All handwritten entries must contain two signatures. 2) All eye drops must have recorded the date of opening. 3) All medication dispensed must be signed for by the person dispensing at the time of administration. The registered person shall 30/10/06 ensure that all parts of the care home are kept reasonably decorated. 1) Bedrooms as discussed during the inspection. 2) The corridor area by the lift on the 1st floor. DS0000034955.V298586.R01.S.doc Version 5.2 Haddon Nursing Home Page 22 4. OP19 23(2)(B) The registered person shall ensure that the care home is kept in good state of repair. Majority of door frames of residents bedrooms are in need of repair and redecorating 30/10/06 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 OP19 Good Practice Recommendations It is strongly recommended that a re-decoration programme be devised to ensure the standard of decoration is maintained to a high level. Haddon Nursing Home DS0000034955.V298586.R01.S.doc Version 5.2 Page 23 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.V298586.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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