Inspection on 22/09/05 for Evergreen Partnership

This inspection was carried out on 22nd September 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen Partnership 19/01/09

Evergreen Partnership 29/01/07

Evergreen Partnership 23/01/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Evergreen Partnership Maple House Woodmansterne Lane Wallington Surrey SM6 0SU Lead Inspector David Pennells Unannounced Inspection 22nd September 2005 14:30 Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 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 Partnership DS0000062089.V253827.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 Adults 18-65. 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 Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Evergreen Partnership Address Maple House Woodmansterne Lane Wallington Surrey SM6 0SU 020 8254 9403 020 8254 9403 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) Jaqueline Cook Maureen Edith Collyer Daniel Royston Roberts Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not applicable – registration recently granted. Brief Description of the Service: Maple House (Evergreen Partnership) is a substantial house set on the southern outskirts of Wallington in Sutton borough, close to a bus stop, which can provide transport to Carshalton, Purley or Croydon. Being situated just off a roundabout, the entrance to the property can easily be missed, but once recognised, there is a driveway - which provides parking, on site, for a number of vehicles. The house, opening as a service in mid-2005, is substantial; providing four good-sized bedrooms for service users, and substantial communal space (separate lounge / dining area / sun lounge), and adequate toilets and bathing facilities. There is a large rear garden area, with plans to use some of the garden - which is split into two – for growing vegetables – which ties in with the location, as Maple House is close to market garden outlets; the whole area has an ‘agricultural’ or ‘countryside’ perspective to it. The service – non-smoking, inside - is designed to provide for four service users with learning disabilities and associated challenging behaviour, aiming to provide service users with “a range of opportunities to support and empower people…to enjoy a fully enhanced quality of life whilst supporting them to make informed decisions and choices about the way they would like to live…The focus will be on fun, choice, good health, enjoyment and comfort, providing people…the opportunity to expand their sphere of experiences and to develop their lives in creative and imaginative ways supported by a highly skilled and experienced staff team” (extracts from the home’s Statement of Purpose). Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, and designed to introduce the inspector to the home and vice versa; the first service user had been resident at the home since early July and the inspector felt this was a good opportunity to explore how they were settling down, how the home was bedding in its practices and to familiarise himself with the building prior to it becoming fully occupied with four service users. The Inspector arrived at the home at 2.30pm and left at about 6.00pm; during this time he was able to tour the premises, examine record keeping and care planning processes, meet and discuss issues with staff members – including the registered manager, Danny Roberts - and he meet and chatted to the sole service user, who returned from her day care centre about half way through the inspection visit. The visit was seen very much as an initial ‘advisory’ visit – as clearly many systems were just bedding down; it was felt that this was the best time to intervene on the ‘basics’ - so that the service provider could feel confident that they were going in the right direction - and to reassure the Commission that the practices were in line with both the Statutory and National Minimum Standard frameworks. What the service does well: The home is a fine building – very much a family house and has good accommodation facilities for all four service users; wisely the rooms are not furnished very heavily, as there is an expectation that familiar furnishings, etc, will come with a service user when they move in. The establishment appears to be meeting the individual needs of the one current service user well – though there is still a ‘learning curve’ in place as they get to know each other. Certainly the service user appeared settled and very much ‘at home’. Bearing in mind the fact that the home has been established from ‘scratch’ the progress is good; most paperwork / documentation / records is in place and facilities generally are of good and durable quality. This initial visit, despite the ‘glitch’ over the obtaining of CRB documentation, has shown a home that will soon be well prepared for welcoming its next guests, and should establish itself to capacity very quickly. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Prospective service users can be assured that sufficient information is available, for them and other interested parties, to assess the suitability of the service prior to admission – through the Statement of Purpose provided by the proprietors and other documents. Service users will be assessed using a comprehensive assessment tool – as well as the placing authority being obliged to provide information; this will; lead to an accurate assessment of need and a decision as to whether the home is able to provide a suitable service to the applicant. EVIDENCE: The home has a good initial Statement of Purpose - describing the premises, the staffing, the aims and philosophy of care and itemising areas to be addressed and described under Schedule 1 of the Care Homes Regulations 2001 and Standard 1 of the NMS. The documentation for the one service user resident in the home was examined. The home had an assessment tool, which it had used - and a full care plan and appropriate risk assessments were in place. The admission was somewhat of an ‘emergency admission’ eventually, (via a respite Care Unit and another residential placement) and the placing authority had not provided an up-to-date comprehensive assessment; a ‘Statement of Need’ created in April 2005 was the most contemporary placing authority document seen. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 9 The inspector was happy with the documentation created / put in place by the home and was pleased to see good ongoing documentation. The only concern – and this becomes a strong recommendation is that any entry made on paper must be signed (which it generally was), and dated (which in many instances was lacking). Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Service users can be assured that they will be involved in the home’s devising of their care plan – and be encouraged to make informed decisions about their lifestyle through careful person-centred care planning. Service users are supported to take reasonable risks; these are documented and shared with the service user. EVIDENCE: A full care plan was in place for the single service user resident, alongside suitably pertinent risk assessments. The care plan was signed by the service user – clearly indicating their involvement with the care planning process. The Care plan was very full and comprehensive; almost to the point of saturation; the inspector recommends that the plan be condensed into an easily read ‘bullet-point’-style summary, which can be easily accessed by the staff members – and referred to on a day-to-day basis when undertaking the task of daily record writing. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15 & 17. The home is focused on providing client-centred activities both outside the home and ‘at home’; encouragement will be provided to service users to participate in local activities as well as formal structured day care provision. Service users are encouraged to remain in contact with family and friends, and these people are made positively welcome at the home. Service users can be assured of receiving a nutritious and healthy diet - in line with best catering practice, and will be encouraged to participate in catering for their own self-development, independence and enjoyment. EVIDENCE: The service user resident at the time of the inspection visit was out at her day care centre (run by her placing authority the London Borough of Merton) and returned mid-afternoon. She currently attends the day centre five days a week – providing contact with her peers and friends from previous placements. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 12 The home is currently investigating and introducing the idea of newer, local clubs (Mencap, etc.), though this may be a slight problem, due to the lack of familiarity of the new location and unfamiliar service users. Staff members are committed to escorting the service user until such times as confidence is built. Other activities engaged in outside the home include: going to the Cinema, shopping – for self and the home, and swimming. In-house activities are designed to respond to the needs and suggestions of the service user; there are a variety of board games and other activity resources provided by the home. This will clearly develop as more service users arrive and express their likes and preferences in this regard. The parents of the service user are made welcome at the home; it is the home’s declared intention to support clients to maintain links with family and friends. The service user has plans to ‘go home’ on a regular basis – maintaining the strong previous links that existed. Telephone contact is also important, and a portable house phone enables calls to be taken in the privacy of individual’s bedrooms. The kitchen is well equipped and there were more than adequate food stocks provided. Food records were kept and indicated a broad approach to nutrition. It was good to see items served with chips being interspersed with ‘more healthy’ salad meals and other styles of cooking (omelettes / roasts / pasta, etc.). The service user was clearly enjoying her food opportunities; the cooking of the meal that afternoon was of interest to her, however it was clear that the staff were expected to cook it! Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Service users can be assured that the home aims to provide personal care in an individually focused and sensitive way, and will seek to promote their health and wellbeing through ensuring appropriate contact with health-care professionals - and also through the home managing any medication regimes, where appropriate. EVIDENCE: The home has established registration for service users with a GP in a local Health Centre in Wallington, along with them now seeking out other health care professionals – such as dentists – to become familiars ‘contact points’ out in the local community. A pharmacist that is relatively local to the home provides the medication supplies. The home has yet to establish an agreement with a pharmacist concerning advice and inspection visits. Medication is provided in MDS (monitored dosage system) ‘blister packs’ – ensuring a safer method of administration than the traditional bottles / packet system. Medication storage and records kept for the sole service user were examined and found well maintained. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 14 The inspector recommends the keeping of a ‘medication profile’ – a long-term record of the prescriptions received by each individual; he offered to provide a suggested template. Advice was also given that a clearer set of criteria should be created against any ‘prn’ (‘when required’) medication, ensuring that staff are given precise guidance as to when to decide to administer medication – ensuring that all other diversions / interventions have been exhausted before resorting to such medication intervention. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Service users can be sure that complaints and comments will be taken seriously and that their opinions are respected and taken into account. The home has provision in place to ensure the protection of service users from the possibility of physical, material or financial abuse or neglect, and has robust procedures to respond to any allegation or suggestion of such acts including support for staff to feel confident to ‘Whistleblow’ if, and where, appropriate. EVIDENCE: The home has a clear Complaints policy in place, and will ensure that all service users receive the policy in an appropriately accessible format. In conversation with the manager it was clear to the inspector that he was conversant with issues surrounding adult protection and the around reporting protocols and eliciting the help of local care management as the independent support / adviser if such incidents arose. The manager confirmed that he had a copy of the local authority Vulnerable Adults procedure, but on examination, this was found to be the ‘old’ 2002 version of the London Borough of Sutton’s document. More recently, the Borough has been circulating a revised 2005 version; the manager was advised to contact the Civic offices to access a copy of the revised version. Financial procedures are in place and include good provision for the safe storage, recording and disbursement of monies and valuables held in safe keeping for service users. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users can expect to reside in a clean, hygienic and comfortable environment, the premises being homely and very suited to the purpose. The home and service is designed to encourage independence, privacy and the maximisation of each individual lifestyle. EVIDENCE: Maple House is a very pleasant well-furnished environment in which to live; each service user has access to extensive well prepared communal areas, as well as a single bedroom each. All bedrooms are over 12 sq metres in dimensions; one of the three bedrooms (the largest) on the first floor has an ensuite shower. On the first floor, also, are a separate toilet, a bathroom with toilet and Jacuzzi spa bath, and the office / staff room. The ground floor has the fourth single bedroom, with a shower-room and toilet close by. The lounge, sun lounge, and kitchen are also off the front hallway; the dining area is off the kitchen area, closer to the ‘back door’ and overlooking the back garden. Garaging at them time of the visit – also close to the ‘back door’ was used for storage at the time of the inspection visit. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 17 The exit door from the sun lounge was currently locked with a key and the inspector recommends it should be considered for a locking device that does not require a key. Although - it is understood - that the Fire Safety Officer does not require this (there are other ‘designated’ exits), it is certainly best practice that all final exit doors be operable without the use of a key. The home has a fully integrated fire alarm system and other health & safety precautions, such as thermostatic mixer valves on hot water outlets, are fitted (see Standard 42 for comments regarding regular checks) as standard. The majority of the house remains ‘pristine’ in cleanliness and decorative order. Bedrooms await the advent of service users to decorate and furnish their own space – and communal areas – though pleasant, again, will become very different once pictures and posters appropriate to the service users’ characters are introduced. The inspector looks forward to seeing the place properly ‘lived in’ – with a few bumps and scratches evident from the service users really enjoying living there! Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The staff team at the home is developing – extra staff are being brought in to respond to the level of need / service user number; thus far, six staff are directly in the home’s employment, with further staff planned to start as the population of the home develops. At the time of the inspection visit the service user was receiving at least a 1:1 service with seniors on call at all times and additional staff coming in during the day to work on developing the service and preparing for the advent of the next service user(s). Currently there are six staff members in place; a manager, deputy manager, two full time support workers, a part-time support worker and a ‘bank’ support worker. Conversations concerning recruitment checks – including references and CRB (Criminal Records Bureau) checks, brought to light the fact that some staff at the home had not had full checks undertaken by the home itself. Since the introduction of the PoVA (Protection of Vulnerable Adults) checks last year, CRBs / PoVAs are no longer ‘portable’ / transferable. Two staff had such ‘transferred’ checks (undertaken in December 2004 and June 2005) by other organisations – and these were NOT, any longer, recognised in regard of the service provided at Maple House by Evergreen Partnership. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 19 The inspector (following consultation with his line manager, and after conducting a risk assessment of potential harm which could arise for the service user) issued an Immediate Requirement Notice on the home - to ensure that CRBs were immediately undertaken with regard to those staff for whom there was no directly applied-for CRBs, and to ensure that evidence in regard to a third [bank] staff member – whose PoVAFirst check had not been evidenced by the umbrella body acting on behalf of the Partnership – was provided to the Commission without delay. Bearing in mind the specific circumstances of this particular case (previous recent checks from elsewhere and full references and other recruitment checks), it was felt that the staff in question could continue working along aside the service user for a short time until the paperwork was regularised. At the time of writing this report the inspector is pleased to report that the Immediate Requirement Notice – served on the home the following morning (23.09.05) – has now been fully complied with, and all immediately necessary checks through the CRB have been undertaken, thus satisfying the Notice in its entirety. Notwithstanding this CRB problem (which to some extent was created through lack of knowledge / inadequate information being provided to the provider by the umbrella body used), the home appeared to be getting its staff records into order. Employment issues will be a major focus of the next inspection visit. The manager was provided with a copy of the revised Schedule 2 of the Care Homes Regulations 2001 – to ensure that such a list is used as a checklist for recruitment documentation, and to – at the same time – ensure compliance with the statutory requirements set under the Care Standards Act 2000. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 & 42. The home is well organised and run on a basis of positive leadership, this stemming both from the manager of the home and also the registered providers. The health, safety and welfare of service users is generally well protected, though attention must now be paid to ensuring that all safety provisions are ‘tightened’ and ‘regularised’ - to acknowledge the potential vulnerability of service users now resident at the home. EVIDENCE: The registered manager, has an excellent ten-year background in Health Service learning disability services, and was expressing his keenness to see the home develop, and to become more populated with service users, now that it is properly ‘open’. More recently, Daniel Roberts - the registered manager - has become a father, and he has made a formal decision to hand in his notice at the home to focus Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 21 on the ‘paternity’ aspect of his life. He has stated that he intends to remain in post until a replacement has been found for him. The proprietors of the Evergreen Partnership have also, now, confirmed this information formally to the Commission; they are seeking a new person to take over the management role and to propose as the new registered manager. The two Partners of the owning organisation have undertaken regular visits to the home and are clearly committed and involved in the development of the home. Written reports - as required under Regulation 26 of the Care Homes Regulations 2001 – have been submitted to the Commission, on a monthly basis, since the home formally opened. Touring the home, the inspector was surprised and disappointed to find bleach in a bottle openly available in the bathroom, and again, later, other cleaning fluid container in a bucket - in an unlocked storage cupboard. Fire Drills were yet to be commenced; these were required to be started immediately, ensuring that staff members are all involved with the Drill, along with the service user being familiarised with such a measure. Fire alarm checks also must now be regularised; they were not held on a regular cycle at the time of the inspection visit. It is required that tests are held at the same time on the same day each week - to ensure that complacency does not develop, and to be clear to staff members and service users that the bells ringing at any other time is ‘for real’. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Evergreen Partnership Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 2 X DS0000062089.V253827.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 YA34 Regulation 19(1) Requirement Issued on 23.09.05 as an Immediate Requirement Notice: Timescale for action 30/09/05 The registered providers must seek without delay, full, enhanced CRB & PoVA checks for all staff at the home in the name of Evergreen Partnership. PoVAFirst checks must be requested, and evidence furnished to the Commission that these, and full CRB checks, have been obtained. 2 YA42 13(4) Any cleaning fluid / chemical 22/09/05 must be kept locked away - at all times - to obviate any risk of misuse. Fire drills must be built into the home’s routine from the day of the inspection onwards; drills must be fully recorded and each new staff member must experience a drill as soon as it is practicable. The service user must be involved in some (but not necessarily all) of the drills. Fire alarm checks must now be regularised to the same time on the same day each week and DS0000062089.V253827.R01.S.doc 3 YA42 23(4) 30/09/05 4 YA42 23(4) 30/09/05 Evergreen Partnership Version 5.0 Page 24 recorded - to ensure that staff and service users are clear that the bells ringing at any other time is ‘for real’. 5 YA42 13(4) Checks of the maximum hot water outflow from hot water taps must be regularised and undertaken each week and a record kept. 30/09/05 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 YA2 Good Practice Recommendations All records kept at the home should be checked to ensure that they are consistently signed and dated to endorse and identify their currency. It is recommended that service user Care Plans be ‘condensed’ into ‘bullet points’ – to enable easy access for staff to the main points, goals and targets set. A medication profile should be established for each service user – enabling the home to record the medication / prescription history of each service user (suggested format to be provided). The criteria for the administration of ‘prn’ medication should be set out in a document designed for this purpose giving clear guidance to staff as to any strategies that should be considered if appropriate to avoid the need to administer such additional medication. The home should seek out a pharmacist that is willing to enter into an agreement with the home concerning providing advice and inspection visits to the home. The manager should access the new 2005 revised London Borough of Sutton Vulnerable Adults / Adult Protection policy from the appropriate council location, and ensure DS0000062089.V253827.R01.S.doc Version 5.0 Page 25 2 YA7 3 YA20 4 YA20 5 YA20 6 YA23 Evergreen Partnership that its content is known and integrated into the home’s own VA / AP policy statement. 7 YA24 The exit door from the sun lounge should be considered for a locking device that does not require a key. Although it is understood that the Fire Safety Officer does not require this, it is best practice that all final exit doors be operable without the use of a key. Evergreen Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Partnership DS0000062089.V253827.R01.S.doc Version 5.0 Page 27 - 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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