Inspection on 09/04/08 for Evergreen Residential Home

This inspection was carried out on 9th April 2008.

CSCI found this care home to be providing an Adequate service.

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

Similar services:

Elmleigh Convent

Eastfield Farm Residential Home Limited

Cranwell Court Care Home

Fairview

Cottingham Hall

Cranmer Scheme

Fairburn Mews

Claremont House

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

CARE HOMES FOR OLDER PEOPLE Evergreen Residential Home 22 Prince Of Wales Terrace Scarborough North Yorkshire YO11 2AL Lead Inspector Karen Ritson Key Unannounced Inspection 9th April 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Evergreen Residential Home DS0000070816.V363003.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. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Residential Home Address 22 Prince Of Wales Terrace Scarborough North Yorkshire YO11 2AL 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) 01723 375122 Caliburn Care Homes Ltd Care Home 17 Category(ies) of Dementia (17) registration, with number of places Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of service users who can be accommodated is: 17 03rd January 2008 2. Date of last inspection Brief Description of the Service: Evergreen is a Victorian terraced property located in the South Cliff area of Scarborough, within walking distance of the Esplanade. The home is registered to provide residential care for seventeen residents over 65 with dementia. The home is located on the first five floors. A lounge is located on the lower ground floor and a dining room on the ground floor, stairs or a passenger lift can access all floors. The care home does not have a garden but is conveniently situated for access to the main community facilities including the public transport network. Restricted on road parking is available. The home has a statement of purpose and service user guide, which provide information about the scope and nature of the care and facilities on offer. These, with CSCI reports, are available on request at the home. The fee charged is £359.50 per week. Hairdressing and newspapers are not included in this fee and these are charged at cost. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection for this service took 22 hours. This includes time spent gathering information and examining documentation before and after an unannounced site visit and in writing the report. The CSCI pharmacist accompanied the lead inspector on this inspection and her findings are incorporated into the report. The site visit took place on 09/04/08 between 09:30am and 18:15 pm. Information for this inspection was gathered from the following: • • • • • • • • • A tour of the premises Observations of care throughout the day of the site visit. Speaking with people living at the home. Speaking with staff on duty at the home. Case tracking service users on the day of the site visit. Notifications sent to the commission from the home since the last inspection. Examining policies, procedures and records kept at the home. Examining information regarding the home on the file kept by CSCI. Considering comments made by relatives, health care and social services staff. All key standards were looked at during this inspection. The manager was available throughout the day and the registered provider was present for feedback following the inspection. What the service does well: Evergreen is a new service following the purchase of the home by Caliburn Care Homes Ltd. The company have appointed a new manager since the last random inspection. The manager consults health care and other professionals to make sure the care offered follows their advice. Visitors are made very welcome. One visitor said: ‘They are all very welcoming and we are always offered tea or coffee.’ The quality of food is very good. One person said: ‘You can’t find fault with the meals they are always really nice and well set out and there is a good choice. The staff know about the meals most like best.’ Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 6 Staffing levels are satisfactory for the number of people living at the home. What has improved since the last inspection? What they could do better: Medication handling must be improved to fully protect those living at the home. The plan of activities must be completed for each individual so that appropriate recreational and social time is fully based on the interests and needs of each person. The décor and layout of the home should be considered and improvements made to create a more pleasant living environment. Staff must all be capable of offering the care required for people living at the home. This is not the case at present. All staff must be recruited according to policy and procedure; this has not always been the case since the last inspection. The manager must devise an effective quality assurance system and must complete safe working practice risk assessments. Health and safety documentation must be up to date and safety certificates must be available at the home for examination. Laundry provision does not fully protect people living at the home from the risk of cross contamination, and the laundry room needs refurbishment. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People who use the service experience good quality outcomes in this area. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: No new admissions have been made since the last random inspection. One person has been moved from the home, as his care needs could no longer be met. This shows that the home uses the assessment process to help make decisions about whether appropriate care can be offered when needs change. Assessments on file were carried out by the previous manager. These covered most of the areas required. Since taking up post the new manager has compiled assessments written in a narrative form in order to address needs particularly in relation to challenging behaviour and exploring methods of communication for those people who may not express themselves clearly due Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 10 to a dementia or other condition. These assessments are to be used until updated care plans are put into place. Most staff have the necessary skills and knowledge to offer the care needed, however, not all do. Staff have completed a programme of training and this has highlighted where some staff require added support to understand the needs of the people living at Evergreen. The home does not provide intermediate care. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. Care planning has improved which helps ensure people receive appropriate care however, the health and personal care that people receive is not fully based on their individual needs due to shortfalls in medication handling. The principles of respect, dignity and privacy are put into practice. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The new manager has been in post for five weeks. In this time she has created new care plan folders, with a structured record for care needed and separate sections for recording health care and social visits. These are not yet complete. In the meantime staff continue to refer to the existing care plans for day to day care. New care plans are being created using information from the existing plans, relatives, staff knowledge, medical and other professional input where necessary. Most care plans include risk assessments for falls, Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 12 moving and handling and challenging behaviour. Other risk assessments are being completed as necessary. People are weighed regularly and more often if there are concerns about weight loss or gain. Challenging behaviour risk assessments have been improved. Staff training and management in this area has improved since the last random inspection. Staff reported that the manager and another senior member of staff gave a clear lead in managing challenging behaviour. This senior has recently attended external training in this area and assists in showing staff how to de- escalate situations and how to divert attention to avoid confrontation. Relatives commented that the care was improving. For example one said: ‘They know (my relative) now, and when there are problems they know what to do.’ Another said: ‘(My relative) had a fall recently. The staff did everything they could to make sure she was looked after when it happened. I have no worries about the care she gets.’ A professional visiting the home said. ‘It’s improving. Staff spend time with the residents and it’s a more cheerful place now.’ However, another person said. ‘The staff vary in how well they handle situations. Most are really good, but there are some who don’t seem to have learned what to do.’ The manager agreed that some staff needed extra support and were not yet offering care which fully met the needs of those living at the home. This means that despite improvements in recording and staff awareness the care offered is not yet consistent. The daily recording has improved. Staff now record informative notes on each shift including the night shift. There is also a new communication book, which staff use for extra comments between shifts. This helps ensure that observations and information about people are passed to those who need to know, so that care is appropriate for current needs. A period of time was spent observing people sitting in the lounge and staff interactions with them. Staff were polite and kind when they spoke to people and any difficulties were discretely dealt with to preserve dignity. Relatives agreed that people were treated politely. Staff were also observed knocking on room doors before entering. Pharmacist evidence There is an updated medication policy available but it must detail what facilities there are for the storage of controlled drugs. Also, the section on disposal needs to include that a record must be made of medication returned to the Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 13 pharmacy for disposal. Staff should have access to an up to date policy on all activities involving medication to make sure that safe systems are followed. The current and previous month’s Medication Administration Record (MAR) charts were looked at. There is now a record of staff authorised to administer medicines in the MAR folder. This means it is possible to identify who was involved in administration if a problem or query occurred. There are now photographs of people attached to the dividers between the MAR charts. Having a photograph helps to reduce the risk of medication being given to the wrong person. There were very few gaps against the entries listed on the MAR charts. The accurate recording of antibiotics has improved. The amount of antibiotics recorded on the MAR at the time course complete was written matched the quantity supplied. This means antibiotics are administered as prescribed and helps to make sure infection is treated correctly. There was inconsistency in the accurate recording of handwritten entries. The date of entry, the quantity supplied and a signature of the person making the entry were missing. To make sure there is an accurate record this information should be included, with a witness signature where possible. The use of codes to explain why medication has not been administered remains poor. A number of entries had the code M used to record that medication was not required. This is the wrong use of this code as there are other codes on the MAR chart to identify when medication is not required or refused. The code M on the MAR chart is defined as make available which suggests there was no stock available. However each time code M was used medication was available to administer from. The code ‘F’ was regularly used to record no administration, however there was nothing written on the MAR to explain what the code meant. It is important that a clear reason is given when medication has not been administered. The accurate use of codes provides information on how a person is taking their medication. The prescriber, who may wish to review the medication, may also use this information. A number of entries had the code G used to record no administration because there was no stock available. A system must be in place to identify how much stock there is for the person so that more supplies can be ordered in plenty of time. This will prevent the person from being without their medication, which may affect their medical condition. An opened bottle of Calogen food supplement was found in the trolley. This should be stored in the fridge after opening. The manufacturer’s instructions for storage of medication should be followed to make sure it is safe to use. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 14 There is still no controlled drugs cupboard or register. A controlled drugs cupboard and register must be in place to make sure that the storage and recording of controlled drugs meets legal requirements. The manager has developed a system for the ordering of monthly prescriptions and recording communications with the supplying pharmacy. This is an example of good practice as it provides an opportunity to check that the supply of medicines is accurate. The prescriptions once issued by the GP surgery should be sent to the home before going to the pharmacy. This adds an additional check to the process and allows for any problems to be identified and dealt with before the supply is made. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: A senior member of staff has taken on the role of activity organiser and has begun to structure activities offered to people. Staff were observed spending time with people in the lounge, talking with them and reminiscing, people were also clearly enjoying throwing and catching a large beach ball to one another. Another member of staff was spending time on a one to one basis with a person, identifying objects on picture cards. Most people appeared engaged and involved in what was happening and some were smiling or laughing. A relative said staff were spending more time doing things with people than before and this created a ‘nicer feel’ to the home. Each care plan has an activity log where the involvement and response of each person living at the home is recorded. This helps staff understand the interests of each person and to plan future activities. A developing key worker system also helps staff Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 16 to get to know residents well. A representative from the Alzheimer’s society is booked to carry out a training session with the manager and staff about the effects of dementia and how to improve people’s experience of life in the home by offering appropriate activities. The manager and activities organiser are also booked to attend a course which addresses improving the quality of life for people who have a dementia. This training should assist with offering appropriate activities. Visitors are invited to call at all reasonable hours. Several people visited during the inspection and confirmed they were always made welcome. The home has a designated cook who has had food hygiene training and is due to update this in the near future. He reported that he offers a choice of main meal, and that people are asked what they would prefer. The menu for the day is displayed on a chalkboard, which means that people and their visitors may see the menu and choose what they would like. The cook orders fresh produce locally and cooks fresh vegetables every day. This helps ensure people receive a healthy diet. People living at the home, relatives and other visitors confirmed that the food was of a good quality and that visitors were invited to eat at the home if they wished. A midday meal was observed and people appeared to be enjoying their food. The tables were attractively set out and the meal looked appetising. There was a calm pleasant atmosphere and there were sufficient staff on duty to assist those who required help. Other than a diet controlled diabetic menu, none of the people currently living at the home require a specialist diet. The cook said specialist diets would be catered for if necessary. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. They are able to express their concerns, and have access to a robust, effective complaints procedure. People are protected from abuse although certain staff require extra support to do so and people have their rights protected. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: CSCI have received no complaints since the last inspection. Any concerns raised by members of the public have been dealt with by the new manager in a timely and thorough manner and have been recorded with outcomes. Relatives and visitors were spoken to and they reported that the manager had arranged a meeting to introduce herself to them and had encouraged people to come to her with any concerns. One person had done so and reported that the concern had been looked into and that she was satisfied with the response. The manager has also met with staff and talked to them about the importance of open communication. Staff said they thought they could trust the new manager to do what she said she would do and that they would go to her with any concerns, though they acknowledged it was soon after her appointment and they still needed time to get to know her well. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 18 Staff have received external training in abuse awareness and challenging behaviour training from the manager. The manager has past experience and training in the managing of challenging behaviour, safeguarding and abuse awareness. A senior carer has been on recent training in challenging behaviour also. CSCI have received notifications about incidents as required. A person living at the home had been injured recently following a fall. The local GP surgery reported that the quality of information given to the GP on duty at that time had been good. Social services staff had called at the home to check the care offered to this person was satisfactory and found that is was. A relative said: ‘The staff know how to handle (my relative) now. They can distract (my relative) and things don’t get so heated.’ Visitors and relatives confirmed that some staff still required extra support in how to deal with behaviours. A representative from the Alzheimer’s society had also spoken to staff recently about how to de -escalate situations to avoid confrontation between people and staff. Staff said they felt more confident about how to deal with challenging behaviour and knew what they would do if they suspected abuse. The home has a new policy on abuse and reporting procedures, and a new complaints policy which is available to visitors in the statement of purpose and on request. In practice the manager acknowledged that all staff have not reached the desired level of competence in dealing with challenging behaviours and that whilst this area had improved there was still a degree of inconsistency in the level of care offered. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. The physical design and layout of the home does not encourage independence. The home is reasonably decorated but needs refurbishment. People receive an adequate laundry service and infection control procedures are also adequate. People are protected from risk of fire. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: A tour of the premises was conducted. The home has been routinely maintained since the last inspection. The home is clean and smells pleasant. There is a good ratio of staff to people living at the home and these staff are well deployed with the result that people appear less restricted in their movement around the home than before. The lounge is now located on the Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 20 lower ground level of the home, from which there is access to a toilet. The dining room is on the ground floor. The manager has plans to allow communal access to all people living at the home on the ground floor with the added benefit of toilet facilities on this level. This work has not yet been carried out but would create several lounges from which people could choose. Those who benefit from moving from room to room could do so in safety and without needing help from staff to access another floor of the building. The home would benefit from improvement in interior décor. One visitor said; ‘The place looks a bit shabby.’ The home has an up to date fire risk assessment and the environmental health department has visited. All requirements are being addressed with plans in place. Laundry continues to be carried through the kitchen to the laundry room at the back of the home. However, this is now carried out in a manner which reduces the risk of cross contamination. Laundry is carried in sealed bags when food is not being prepared. The laundry room is in need of renovation. Laundry provision would benefit from being relocated to fully prevent the risk of cross contamination. People said the quality of the laundry provision had improved with fewer clothes going missing and clothes not being damaged. Staff have had recent training in infection control and when questioned understood how to avoid the spread of infection. This helps protect the health of people living at the home. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. Staff in the home are trained and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. Some staff require extra support to provide an adequate level of care. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home is adequately staffed for ten people with three carers on duty during the morning; (one a senior), two in the afternoon, with the manager or a senior on duty and two waking night staff. There are separate domestic and cooking staff. The manager is also on call at night and during most weekends and lives within walking distance of the home. The night staffing ratio would need to be re assessed if the home was at capacity. More than 50 of staff have NVQ at level 2 and several are enrolled on a course to complete this training. A training professional said most staff were keen to learn although there were some staff that did not yet have the qualification who needed prompting and did not seem to have the motivation required to complete the work. The manager said she was aware of this and was approaching each member of staff in one to one supervision sessions. One new member of staff has been recruited since the last inspection but before the new manager was appointed. This staff recruitment file did not all Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 22 contain the correct information. This member of staff had been taken on with a poorly completed application form and insufficient other information. This member of staff no longer works at the home. Other staff files contained sufficient information. All staff have received moving and handling training, updated training was planned for April. Most staff have first aid training and those remaining are to have this at the end of April. Some staff have had infection control training and more is planned mid April. All staff received an update in fire training in January 2008. All staff have received basic training in dementia awareness and some are to commence a course which is more detailed. Confirmation was received from the manager after the inspection that all statutory training above did take place on the booked dates. This helps ensure that people living at the home have their needs properly met. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38. People who use the service experience adequate quality outcomes in this area. The management and administration of the home is based on openness and respect, the manager is competent and qualified to run the home. Quality assurance systems have not yet been developed, people are protected by the way in which the home handles their personal allowances but are at risk due to a lack of safe working practice record keeping and risk assessments. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The owners of Evergreen care home have appointed a manager who had been in post for five weeks when the inspection took place. The manager has the Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 24 Registered Managers Award, D32/33 and is also nearing the completion of her NVQ level 4 in care qualification. She has experience in previous care home management and has worked with older people and people with a learning disability. She has begun training in dementia care and since her appointment has consulted professionals with specialist knowledge about the needs of people who have a dementia. She demonstrates a sound understanding of staff management and person centred care and has begun to put her knowledge into practice within the home. People coming into the home either as visitors or as professionals reported that the home was well managed, that they were consulted about care and any comments had been taken on board and acted upon where necessary. Staff said the manager was approachable and had encouraged them to consult her if they had anything they wished to discuss. Her application for registration with CSCI has not yet been received. The manager has begun an internal audit and quality assurance system, but this was not yet fully operational. However, some feedback about care in the home had been gained from consultation and people reported this was already being acted upon and that care was improving. Regulation 26 visits are routinely taking place, where the provider visits the home and reports on the quality of care being offered. These reports are sent to CSCI. Personal allowances are looked after for some people at the home. Personal allowance money for two people was checked against records and was correct. The home protects the welfare of people living at the home through increased training of staff in foundation level care such as moving and handling, first aid, fire safety and infection control. This training has been carried out since Caliburn Care homes took over ownership of the home and was completed at the end of April following the inspection date. However, people are not fully protected by risk assessment of safe working practices. The manager has yet to complete these and the existing risk assessments are inadequate. Gas safety and electrical safety certificates could not be produced. The provider has agreed to produce these certificates within one and six months of the inspection date. The home does not yet have a regular record of hot water temperatures. The manager planned to introduce regular safety audits as soon as possible and was aware of the shortfall in this area which must be addressed quickly to protect the welfare of people living at the home. Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 25 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 x 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x x x 1 Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 26 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 OP7 2 OP9 13 Standard Regulation 15 Requirement Care plans must be updated to provide detailed guidance for appropriate care. A controlled drugs cabinet that meets legal requirements must be obtained. This means that any controlled drugs received will be stored correctly. A system must in place to make sure there is enough stock of medication to administer. This helps to make sure a person receives their medication correctly and on time and that their medical condition is not affected. Medication must be stored as recommended by the manufacturer. This makes sure the medicine is safe to use. 4 OP12 12 Previous timescale 03/02/08 The manager must complete the assessment of social and recreational needs of people with a dementia and to provide people with appropriate individualised choices of activity. DS0000070816.V363003.R01.S.doc Timescale for action 09/07/08 09/07/08 3 OP9 13 09/05/08 09/07/08 Evergreen Residential Home Version 5.2 Page 27 5 OP18 13 6 OP19 23 7 OP29 18 8 9 OP31 OP33 19 24 10 OP38 13 The registered person must address staff competence so that all staff are capable of protecting people from abuse. The living space of the home must be arranged to offer maximum support to those people who have a dementia in line with the statement of purpose. The manager must ensure that staff are only recruited following appropriate checks and that references are obtained prior to beginning work at the home in order to safeguard the welfare of people living there. The manager must be registered with CSCI. The registered provider must make provision for the review of quality care for care to people living at the home. The registered provider must produce evidence of a gas safety certificate and an electrical safety certificate. Risk assessments for safe working practices and regular auditing must take place to ensure the safety of people living at the home. 09/06/08 09/12/08 09/04/08 09/07/08 09/10/08 09/10/08 Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP9 OP9 Good Practice Recommendations The medication policy needs to be updated, to make sure staff are working to current legislation and guidance. For accurate information on MAR charts all handwritten entries must have detailed information and a witness signature where possible. Codes used to record why administration of medicine has not taken place must be clearly defined so detailed information on a person’s medical treatment can be obtained. Regular, monthly prescriptions should be seen before sending to the pharmacy. This makes sure a check can be made that all the medicines required have been listed and prevents people from being without. The registered person should give consideration to how laundry may be carried out without bringing it through the kitchen, to avoid all risk of cross contamination. The laundry room should be re decorated and kept at a reasonable temperature for staff to work in. 4. OP9 5. OP26 Evergreen Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Residential Home DS0000070816.V363003.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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