Inspection on 23/01/06 for Evergreen Partnership

This inspection was carried out on 23rd 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 no outstanding requirements from the previous inspection report, but made 2 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 22/09/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 Announced Inspection 23rd January 2006 10:30 Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 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.V281504.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 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.V281504.R01.S.doc Version 5.1 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.V281504.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd September 2005 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 into the local Carshalton, Purley or Croydon areas. 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 at the front of the house, for a number of vehicles. The house, opened as a service in mid-2005, is substantial; provides four good-sized bedrooms for service users, and substantial communal space (a 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 appropriately with the location, as Maple House is close to market garden / garden centre outlets; the whole area has an ‘agricultural’ / ‘countryside’ perspective to it. The service - a non-smoking facility - 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.V281504.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection - the second to this new service - was announced, as the inspector wished to ensure that the manager was available to enable access for him to all areas, and to speak of the home’s direction for the future. The inspector was able to discuss issues with the manager - Danny Roberts, and also met the deputy and other staff - including one new member currently on induction - and to meet one of the proprietors - Jaqueline Cook. The inspector is grateful for the welcome, the cooperation, and the hospitality shown. The home continued to provide accommodation for only one service user - a female, admitted at the beginning of July 2005 - who continues to thoroughly enjoy her time at the home, it became apparent. The service is now looking forward to welcoming a second service user, and the staff and the current resident were eagerly awaiting the arrival day. Obviously up to this day the service has been provided on a one-to-one basis - and the service user returns to their parents for weekend breaks - so the growth of the community and the service into a more continuous input will see the house fully operational soon. The service user was out at their day care setting during the day - but the inspector was able to spend some time - including an interview in private with her, hearing about her general lifestyle and her opinions of the service. The service user’s parents had also replied to a Commission-created questionnaire - evidencing their general contentment with the service, from their perspective. What the service does well: The home is a fine building – very much a family house, and has good accommodation facilities for all the 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 - indeed it is hoped some may be decorated to suit their tastes prior to occupation. The establishment appears to be meeting the individual needs of the one current service user very well – though there is soon to be a second ‘learning curve’ in place - as the second service user arrives and everyone gets to know each other. Certainly the current service user is well settled, and very much ‘at home’ at Maple House. As reflected at the last inspection visit: “bearing in mind the fact that the home has been established from ‘scratch’ the progress is good” - and continues to be so; paperwork / documentation / recording is well in place and facilities provided are generally of a high and durable quality. The sole service user also reports positively ion the service actually provided. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 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.V281504.R01.S.doc Version 5.1 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.V281504.R01.S.doc Version 5.1 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 & 4. 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 can be confident that their needs and goals 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 aspirations - leading to a decision as to whether the home is able to provide a suitable service to the applicant. Service users can be assured that the process of familiarisation to the home will be taken seriously and applied in the most suitable way to encourage integration within the community at Maple House. EVIDENCE: Admission and assessment information was available for the current service user, and certain assessment and core information was ready in place for the next (imminent) service user’s arrival. 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. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 9 The documentation for the one service user resident in the home was again examined. The home has an assessment tool, which it had used - and a full care plan and appropriate risk assessments were in place. The inspector’s previous concern under Standard 2 – a strong recommendation resulting at the last visit - was that entries made on paper must be both signed and dated. Clearly, the documentation in place at the home was now more rigorously kept, and the ongoing paperwork was well maintained. Again, details of the admission process were difficult to gather, as the second service user’s placement was still a while off; the staff were excited at the prospect of visiting the service user in their current placement in order to start familiarising themselves with them and their routines. Due to the distance of the service user away from Wallington, it had been agreed that visits to the house would not serve a useful purpose; the initial placement period would serve as the ‘introductory’ sequence to the home. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 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): 7, 8 & 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 can be assured that they will be involved in all aspects of decision-making in the home - as the home evolves, this will be a learning curve for all involved. Service users are supported to take reasonable risks; these areas are generally documented and shared with the service user - though a more generic assessment format would be useful to consider all aspects of possible risk at the outset. 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 planning process. Standards 6, 7 & 9 were assessed at the previous visit and were all found ‘met’, apart from a recommendation being made against Standard 7 - where Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 11 the inspector suggested that care plan documentation should be abbreviated to ensure that the principal points were available in ‘bullet point’ form - to enable ease of reference and to encourage recording focused on these goals / aspirations. The inspector was able to examine the abbreviation of the current service user’s care plan - which was still substantial - but nonetheless more accessible through its being reduced from a substantial document. The above judgement statements reflect the situation concerning the standards previously inspected (6, 7 & 9) - and standard 8 this time is also found ‘met’. Standard 8 focuses on participation and consultation about life in the home and the current service user’s views and opinions have clearly been taken into account entirely along the way. The service user confirmed that she is involved in all major decisions about her care and appreciates the staff care - “I adore the staff” she stated, when asked how she gets on with them. The service users is clearly being well prepared for the ‘shock’ of a second person coming to live at the home - acknowledging that it will be a “shock” - but looking forward to having company - “someone to have a chat with”, although she did state that she already has this facility - which she appreciates - with the staff members already being around her. The coming of ‘company’ for the existing service user will change the entire focus and culture in the house - and the manager and the staff are clearly preparing themselves for the transformation this will bring. Risk assessments are in place appropriately for the current service user, based on the comprehensive assessment and the home’s ongoing assessment. General house-focused risk assessments have also been completed. A generic risk assessment format is required, however, to initially (and progressively) countercheck all possible avenues of risk against each individual service user this ensuring that the process is as proactive as is possible. Such a checklist may well have a substantial ‘nil-return’ for more capable service users, however it is best to consider all aspects of possible risk from the outset - and develop specific risk assessments from this baseline. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 12 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): 14 & 16. 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. Leisure opportunities will be facilitated through staff being familiar with likes and dislikes and enabling engagement with as much preferred activity as is possible. 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 expect their rights to be respected and upheld through a relaxed culture in the house and through choice being promoted. 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. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 13 EVIDENCE: Standards 11, 12, 13, 15 & 17 were inspected at the last inspection visit and their assessments are still applicable; all such standards were found ‘met’. Some narrative from that report is reiterated here for the reader to form a fuller impression of these standards, alongside comments about the two inspected this time - which also were found ‘met’ (see second and fourth judgement statements above). The service user ……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. The home is currently investigating and introducing the idea of newer, local clubs (Mencap, etc.)…Staff members are committed to escorting the service user until such times as confidence is built. Activities engaged in…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…. 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. Telephone contact is also important, and a portable house phone enables calls to be taken in the privacy of individual’s bedrooms. The service user confirmed that the daily routines of the home do not obstruct her right to freedom of choice - though an incentive does have to be given (agreed with the parents and care manager) around her attending the day care centre regularly. She has a key to her own room - and staff members respect this as her private space. Staff members positively interact with the service user and she is clearly still the ‘centre’ of attention - though the service user did confirm, for herself, that she enjoys spending time on her own in the evenings - in her room with her computer of the television. 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 stated that the food was good and she really enjoyed it especially spaghetti bolognaise - though she was still reticent to get too involved with its preparation. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 14 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): 21. 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. Service users can be assured that they will be supported when ill, or as they age, or pass away, with appropriate steps being taken to ensure sensitive and individualised care, once sufficient detail in these regards is held on site. EVIDENCE: Three of the above standards were found ‘met’ at the previous inspection with little or nothing changing to contradict this. The final standard was inspected this time and found ‘met’ - though a recommendation is made. Healthcare support is provided from the Shotfield Health centre in Wallington and the Stafford Pharmacy provides the medication service and also the Pharmacy inspection / advisory visits. Access to other paramedical services such as opticians and dentists will be accessed as much as possible from ‘mainstream’ services unless a specialist focus is advised. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 15 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. A recommendation that 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) had yet to be adopted - and is, therefore, reiterated. The inspector was able to discuss issues around the prospect of ageing and the specific needs of older people - and is satisfied that such provision will be available as necessary. The introduction of policies and procedures concerning ‘continence promotion’ and ‘pressure areas’ in part (but not exclusively) relates to the ageing processes. The inspector does strongly recommend that as much detail concerning the individual’s / relatives wishes concerning steps to be taken should they be taken seriously ill - or suddenly pass away - is kept confidentially on site; this saves much heartache and trauma at the time of an incident, and empowers the home to act in the individual’s best interests. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 16 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): 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: There have been no complaints formally received by the house since it has been open. The standard was fully inspected at the last visit and found ‘met’. The above judgement statements are reiterated from the previous inspection report. With regard to adult protection, one minor issue of concern - regarding an unfounded allegation, had been properly reported to the host local authority, rightly ensuring that exploration of any issues of abuse are transparently investigated. The home has it own policy regarding adult abuse and the current local authority guidelines manual. Financial recording was generally in good order, though it was noted that the service user was not being involved in signing for their personal allowance monies; staff were signing this record only. The manager readily took up the idea of involving the service user in this transaction from then on - so this is made only as a recommendation in this report. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 17 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): 24 - 30. 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: A Fire Safety Officer of the London Fire & Emergency Planning Authority has recently visited the house (20.12.05); the inspection proved to be satisfactory and no matters remain outstanding. A new shower cubicle has been installed in the ‘new’ service user’s bedroom to provide for their needs; this leads to two rooms now having ensuite showers all have washbasins. Two toilets are provided on the first floor level and one is situated downstairs. The following italicised narrative is reiterated from the previous report to enable the description more fully of the house for the reader: “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. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 18 All bedrooms are over 12 sq metres in dimensions; two of the bedrooms now have 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 over-looking the back garden. Garaging at the time of the visit – also close to the ‘back door’ - is used for storage. 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 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.V281504.R01.S.doc Version 5.1 Page 19 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): 32, 33, 34 & 35. Service users can expect staff members to be competent and suitably qualified, and provided at the home in sufficient numbers (in line with minimum standards) to fully meet the needs of service users. Service users can be assured that recruitment practices are fair and ensure their protection and safety. Service users can be assured that appropriately trained staff will be provided to meet their identified needs. EVIDENCE: The staff team at the home continues to develop – more staff members are being brought ‘on line’ in response to the need now to fully establish a 24/7 staffing routine fitting to the level of need / service user number. By the end of January, eight staff members will be directly within the home’s employment, with further staff projected to start as the population of the home develops. At the time of the inspection visit, the service user was receiving 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 second resident service user. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 20 By the end of January 2006 the staffing profile will provide eight staff members: a manager, a deputy manager, four full time support workers, a part-time support worker and a ‘bank’ support worker. Previous conversations concerning CRB (Criminal Records Bureau) checks, brought to light an anomaly - which has now been fully addressed to the inspector’s satisfaction. All staff now have full CRB / PoVA checks completed by the managing company. All necessary references and checks are completed before staff members start employment. Staffing qualifications currently held included nursing qualifications and Health & Social Care certificates - as well as a staff member having a NVQ at level 2 in Care. Both the Deputy Manager and one of the support workers are intending to commence their level 3 NVQ and the remainder of staff are being considered for the LDAF level 2 NVQ certification. Clearly the manager has a critical eye on training potential for staff and the ensuring that levels of staff meet the national minimum standards, or above. Only three staff members were declared to have their first aid certificates, however, and these other ‘statutory’ courses must be borne in mind when the training profile and plan for the home is being confirmed. Staff training undertaken by various of the present staff team includes: Fire Awareness, Learning Disability & Autism, Health & Safety, Analysis & Assessment of Risk, Moving and Handling, Medication Awareness, Adult Protection / PoVA, Food Hygiene, and Learning Disability & Mental Health. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 21 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, 39, 40 & 42. The home is well organised and run on a basis of positive leadership, with a well-qualified and competent manager - supported by the positive encouragement of the registered providers. The views and opinions about the service expressed by service users will be noted and positively taken into account by the registered providers and acted upon. The service provided at the home is underpinned by adequate policy, procedure and record-keeping structures - to ensure consistency of a professional service. The health, safety and welfare of service users is generally well protected, with all safety provision suitably ‘tightened’ and ‘regularised’ - recognising the vulnerability of current & incoming service users now resident at the home. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 22 EVIDENCE: The registered manager, Daniel (Danny) Roberts, had at one point in the past indicated that he was intending to resign - due to personal commitments. This decision has now been reversed and it is for the benefit of the house that the continuity of his leadership will now continue. Danny has a ten-year history of working in this field of social care; his focus must now be on achieving management and care skills to the required level (NVQ Level 4 - Registered Managers Award) approved by the Commission and Skills for Care (the Learning Skills Council). Management responsibilities are fully held by the deputy manager in the manager’s absence, and certain areas are delegated to other members of staff - for instance, two support workers at the house had responsibility for ‘First Aid’ and ‘Medication’ aspects. Quality assurance mechanisms have - on the 1:1 basis encountered thus far at the home - relied on verbal communication and feedback from the service user, her family and interested professionals. It is beholden on the manager to ensure that as the service grows, suitable and adequate mechanisms are put in place to regularly assess the service from stakeholder’s feedback. The service user at the house was happy to report that she felt her comments were heard currently; she reported that she could engage well with staff - who she rated highly - and felt that her opinions were heard. The service user’s parents reported to the commission they were happy with the service being provided overall, and they were kept informed of matters relevant to their loved one. Policies and procedures and paperwork / recording in general was noted to be better organised and evolving well - based on the reality of ‘new’ premises and a single service user to concentrate on. The manager should devise policies and associated procedures with regard to: ‘Continence Promotion’ / ‘Pressure Relief’ and ‘Incidents of Racial Harassment’ to complement policies already in place - and to ensure a comprehensive underpinning of best practice. The Commission’s Pre-inspection Questionnaire sent to the house and duly returned in good time, required details about maintenance and servicing contracts - all of which have been satisfactorily evidenced to the inspector. Fire Drills and associated fire alarm testing provisions are now carried out and recorded. There were no outstanding issues relating to health and safety noted on the day of the inspection; the house was ready for action - and now anxious to provide a service to a full complement of four service users. Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 23 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 Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 3 3 3 3 X 3 X Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 24 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 YA9 Regulation 13 (3) - (7) Requirement Generic risk assessments should be put in place for all activities of daily living for each service user; a basic pro-forma must be devised to ensure that all general risk areas have been considered and appropriate assessments put in place once a risk has been identified. Timescale for action 15/04/06 2. YA35 13(4) First Aid certificates must be 30/05/06 gained by staff who have not yet achieved this; much time can be spent on a 1:1 basis with service users, and therefore all care staff should have at least emergency aid knowledge - if not to a higher level. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 Page 25 1. YA20 That 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). That as much detail concerning an individual’s / relatives wishes concerning steps to be taken should they be taken seriously ill - or suddenly pass away - taken confidentially - should be gained from each individual and kept on file. That service users are included in recording payments of personal allowance by their signing for sums received. That the registered manager should devise policies and associated procedures with regard to: ‘Continence Promotion’ / ‘Pressure Relief’ and ‘Incidents of Racial Harassment’ to complement policies already in place. 2. YA21 3. 4. YA23 YA40 Evergreen Partnership DS0000062089.V281504.R01.S.doc Version 5.1 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.V281504.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!