Inspection on 05/11/08 for Everley Care Home

This inspection was carried out on 5th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Everley Care Home 13/11/07

Everley Care Home 16/04/07

Everley Care Home 30/10/06

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Heathlands

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Everley Care Home 15 Lyde Green Halesowen West Midlands B63 2PQ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jonathan Potts     Date: 2 7 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Everley Care Home 15 Lyde Green Halesowen West Midlands B63 2PQ Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Mani Jethwa,Mr Devshi Jethwa,Shilpa Odedra Type of registration: Number of places registered: care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Five service users in the category of PD(E). This condition will revert back to OP when the placements are terminated. Three service users in the category of DE(E). This condition will revert back to OP when the placements are terminated. Date of last inspection Brief description of the care home Everley Care Home is a detached property located in a residential area between Halesowen and Cradley Heath, not in the immediate vicinity of shops or other amenities. The home was extended and converted by previous owners to its present form; a care home providing personal care to a maximum of 16 service users. The building offers a lounge, dining room, kitchen, laundry and a choice of personal care facilities as it has both a shower and an assisted bath. There are gardens to the rear and car parking space at the front of the property. The home is curently managed by Care Homes for Older People Page 4 of 32 Over 65 16 0 Brief description of the care home the provider (in an acting capacity) on a day to day basis with assistance from a number of senior carers. Other staff include care assistants, a cook and domestic. The curent statement of purpose we saw does not carry the current fee range for staying at the home. We have been told that additional charges include; hairdressing, clothing, private chiropody. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The inspection of the home involved a visit by one inspector on two separate occasions. We received information from the home via an AQAA (annual quality assurance questionnaire) pre inspection and also comments from a number of residents, relatives and staff via comment cards. Evidence was gathered during the inspection by tracking the care for three residents (this involving looking at the records relating to these individuals as well as talking to staff and the residents about their care, or observing how this was provided at the time of our visits). We also toured the home and looked at numerous management and staff records as well as reviewing information received by us since the last key inspection (this including a random inspection we carried out earlier in the year). Care Homes for Older People Page 6 of 32 Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: There is still scope for improvement, the most critical as follows: - There is a need to clarify the directions for some prescribed medications beyond as directed so that staff are clear as to exactly when they should be administered. - There are some carpet joints that need attention to ensure they do not become tripping hazards. - Inventories of residents property in the home need to be completed for all individuals and these need to be accurate. - There are instances where the monitoring of residents weight could be better and the use of a tool to highlight if there are any issues based on weight gain or loss would be useful. - There is scope to develop further the methods of communication staff use with residents that have limited speech or cognitive difficulties. - Further assessment of individuals capacity to consent in respect of the Mental Capacity Act, and how this impacts on their rights and risks that may be Care Homes for Older People Page 8 of 32 present need to be fully explored. - There is a need to keep the use of smaller bedrooms under review in light of individuals potentially increasing physical dependence. - Staff need to have updated training in use of the homes hoist, with consideration of how this may need to be used for any resident that falls on the floor. We also noted some lesser issues referred to in the body of the report in respect of documentation and information. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use the service and representatives have access to most of the information they need to chose a home that will meet their needs. Evidence: Discussion with the acting manager/registered provider showed that she understood the need to ensure that robust assessments are undertaken so that the needs of people admitted to the home can be met. This commitment is underwritten by the homes procedures which have been formulated by a consultant. We saw that the home has a written statement of purpose that is readily available in the home (on display in the reception area) with the service users guide available in residents bedrooms. The statement of purpose we saw did not however have details of the homes current fees for residency, the name of the current acting manager (who is one of the registered providers), nor room sizes. The provider did state that she has Care Homes for Older People Page 11 of 32 Evidence: revised the statement of purpose so as to include this information, although we did not see this at the time of our visits to the home. People did however tell us that they did receive sufficient information prior to admission to enable them to make a decision as to their move into the home. We saw that there are copies of contracts with individuals in their case files although we noted that the information as to any services not included in the fees for residency (i.e chiropody, dry cleaning etc) are not clear (except where top up charges are made which are clear). In addition the number of the room allocated to the individual is not always stated. All other information expected was detailed in these documents however. We saw the admission documentation for the last two people admitted to the home. This showed us that the assessment processes are robust and the home gathers sufficient information so that the acting manager/provider can make a decision as to the homes ability to meet the needs of individuals admitted. This information was seen to include information either from the individuals previous placement or their social worker (in the form of an assessment). We noted that there was no evidence of confirmation of the homes ability to meet needs for the one admission however. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff strive hard to provide personal care in the way that individuals prefer and in a way that promotes their health and well being, although there is scope to improve some aspects of health monitoring. The use of agency staff over the last year has resulted in some compromises to the consistency of personal care but this is improving with more dedicated permanent staff. Evidence: We looked at four individuals care plans and associated records and found that overall the care plans are detailed and carried information that was based on assessments that we saw and reflected the care that was provided to individuals; this ascertained through discussion with them, or observing staff providing care. We only found some minor discrepancies in what was recorded compared to what was provided, these clearly verbally accounted for by the acting manager or staff when raised. We did note that there are instances where improvements can be made, with communication plans whilst in place not fully developed, this significant for one Care Homes for Older People Page 13 of 32 Evidence: resident who has limited communication. The use of flash cards and development of a communication passport would be advisable, this a point the provider stated they would look into. The risk assessments we saw are detailed and generally subject to monthly review. The nutritional risk assessments do not at present link with the home using a recognized BMI monitoring tool, which would assist identification of any issues when there are recorded weight losses. The regular recording of weights would also be a necessity, or use of some other form of monitoring when individuals cannot be weighed, such as measuring the circumference of limbs. People we spoke to told us that the care is good overall although there have been issues in respect of consistency. This is an issue that the provider has told us about due to staffing issues resulting in the use of agency staff, whose use we saw has lessened over the months prior to this inspection. Comments reflected that permanent staff are caring and provide good personal care and less use of agency staff would be expected to improve peoples views as to the consistency of care. People tells us that the staff at the home ensure that they receive appropriate medical support from outside professionals, this as reflected in records that we saw although there was limited reference to facilitating access to dentists. We did however recieve written confirmation from the homes dentist that this service is provided however. Discussion with one resident did highlight some issues in respect of medical advice and their preferences (for example encouraging the resident to walk when they said this was painful). It was clear that the staff were promoting gentle exercise (with positive encouragement seen to be given) in what they thought are the best interests of the individual, although there was some disagreement as to what constituted gentle exercise. Further discussion with the individuals G.P. may clarify the best course of action in this instance. We looked at the medication records for a number of residents and found that overall the homes policy and the practice of the home safeguards residents in this area with the exception of the following: - some medications were written up as to take as directed. The acting manager was advised to discuss this with the prescriber or pharmacy in regard to getting more specific instruction. - One resident has covert medication, this following discussion with the individuals G.P. and written confirmation from the same. As the resident has capacity to consent (as we were told) it was difficult to see why medication needed to be given covertly as when able to consent the individual should make the decision in accordance with Mental Capacity Act guidelines. The issue of capacity does need to be considered in this instance. We saw that the home does usually gain the consent of individuals in respect of the administration of medication and does encourage self administration within a risk Care Homes for Older People Page 14 of 32 Evidence: assessment framework (as we saw in one instance). We were told by residents that their privacy is respected and observation of staff during the course of our visits was seen to be respectful with staff showing this in the way they addressed residents (using preferred tittles) and knocking doors before entry as examples. Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most of the people who live at the home are able to make choices about their lifestyle and are supported to maintain their independence. Social, educational, cultural and recreational activities generally meet individuals expectations. Residents are overall satisfied with the diet made available to them by staff. Evidence: Some of the residents told us that they are able to make choices as to their daily lifestyle and can get up, go to bed when they wish, have freedom to move around the home and have stimulation to the extent that they wish. We did hear that one residents wishes in respect of areas of their life were compromised due to their wish to be less mobile, although staff were seen to be very supportive in encouraging their independence. In this instance there was clearly a need to discuss differing opinions of what was construed as gentle exercise. From discussion with the individual and staff it was clear that the later were acting in what they believed to be the individuals best interests in encouraging and promoting independence and exercise, this based on medical advice. The provider was advised that further discussion with the resident and their G.P. may be helpful. We also saw that whilst the home has agreed a number of issues with individuals in respect of their views on bedroom door keys, consent to be Care Homes for Older People Page 16 of 32 Evidence: photographed and such like, there are no risk assessments in place (in accordance with Mental Capacity Act guidelines) that explore issues of capacity and all potential limitations as a result of this. We have been told by some residents that they receive sufficient stimulation and we saw that during the days of our visits to the home there were organized activities undertaken such as a visiting music and movement session (carried out a by a visiting organization) and a fire works display on the evening. There was a displayed activity programme in the home, this based on activities that had been discussed in the meetings with residents. It was evident that thought is put in to some activities so as to encourage participation such as the armchair Olympics which some individuals told us about, this further evidenced by a photo record of the event. There was comment from a relative that caring staff arrange easter decorations, social events, visitors, keep fit, singing, crafts, celebrate birthdays. We did receive some feedback that one individual felt there was never any activities they could get involved in, this due to their disability which limited them in the activities they felt able to become involved. A representative from the local church visits the home once a month, although the provider did tell us that she was looking to arrange visits to said church to enhance individuals access to spiritual fulfillment. The home has a visiting policy that indicates the home has an open visiting policy with the only request that people avoid mealtimes. Discussion with residents and comments from relatives indicated that this was accurate. 4 out of 8 relatives that responded to questionnaires stated that the home helped residents keep in touch, the other 4 saying this was usually the case. 7 out of 8 stated that they were kept up to date on important issues one commenting staff are always willing to offer information concerning our relative. Individuals we spoke to stated that they enjoyed the meals at the home, although we received comments that the catering was better when the permanent cook was on duty, this having been more of an issue of late due to illness. We saw that residents are offered a choice of meals, these options on clear display on a wipe clean board in the dining area. Whilst we noted that the dining area is potentially to small to accommodate all residents in one sitting although this is not currently problematic as a number of individuals at present chose to eat in other rooms, either the lounge or bedroom. We saw records of foods provided to residents that confirmed that their preferred diets are catered for as detailed in their records. Where residents have difficultly with digestion appropriate diets are provided with supplements as needed. Sight of the meals made available during the course of our visits to the home showed these to be well presented and substantial. We noted that breakfast time is staggered Care Homes for Older People Page 17 of 32 Evidence: and we saw individuals coming in for breakfast at the time they rose, with staff seen to provide extras as requested by residents. Care Homes for Older People Page 18 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and have access to a robust effective complaints procedure, are protected from abuse and usually have their rights protected. Evidence: we saw that the home has an easy to understand complaints procedure that is on clear display and supported by pictorial information. People told us that they are aware of the complaints procedure and the provider/staff usually respond to concerns that are raised. Residents told us that staff listen and respond to what they say. We did however note that the phone number for the CSCI on the procedure is out of date and needs updating to that for our national helpline number. In addition the inclusion of the access number for local social services departments would be useful. We did receive a number of concerns as to the management of the home earlier in the year, these reflecting some issues that the provider had already spoken to us about. Areas of concern that were raised had mostly been addressed at the point we visited the home. In discussion with the acting manager/provider she did tell us that at present informal complaints are not currently recorded, nor responses to these documented. Recording of such would be seen to be helpful in providing a record of any matters that may escalate and any response already made. Care Homes for Older People Page 19 of 32 Evidence: The home has appropriate procedures in place in respect of safeguarding adults and copies of the local authorities safeguarding adults procedure we saw are available to staff in the home. Discussion with staff showed they are aware of the need to be vigilant for abuse and are aware of the need to whilstleblow on poor practice, as has seen to be the case in respect of some matters earlier this year. The provider has identified that there is a need for updated training in adult protection procedures within the training plan for the home and is looking to source this from social services, this to assist with their understanding as to which agency deals with safeguarding issues as the lead body. It was pleasing to see that the staff use body maps to record any observed or unexplained bruises or injuries for all residents. Care Homes for Older People Page 20 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The provider is making continued efforts to improve the suitability of the environment so as to allow people who use the service to live in a safe, well maintained and comfortable surroundings. Evidence: Everley is a home that has been extended a number of years ago to provide the accommodation that is currently presented. We noted that there were areas that required attention on the first day of our visit to the home, many of these addressed by the time we returned, this showing a concerted effort of the part of the provider and staff to improve the home, and make it safer. We saw that there is on going improvements to the home including redecoration in areas, fitting of new lever taps and vanity units in bedrooms. Overall the home presented as homely and comfortable this helped by its overall size although we noted that wear to joints in carpets in some areas needs attention so as to ensure that no tripping hazards are presented. The provider stated that she is looking to have wooden flooring fitted that is easier to clean and more resistant to wear. We did discuss issues noted on the first day of our visit with Environmental Health who visited the home prior to our 2nd visit. We have been told that the home is making satisfactory progress in respect of improving safety since they were awarded a one star rating in respect of food safety earlier this year. Care Homes for Older People Page 21 of 32 Evidence: We received some comment that a wheelchair ramp at the front entrance would be beneficial, this in addition to the rear access. This is a matter that the provider has considered as they suggested the purchase of a fold up ramp that could be employed as needed at the main entrance. Whilst the majority of the bedrooms are of an acceptable size there are two that are quite small (and under current size standards). Whilst this based on discussion with residents and staff this does not currently present any problems (as residents using these rooms prefer a smaller room and staff told us they are physically able to cope within the smaller space) the provider/acting manager was reminded of the need to keep the suitability of the room for the individuals concerned under review. If a point is reached where staff are unable to provide physical assistance to the occupants of these rooms without an unacceptable degree of risk to the individual or staff then movement of the individual to a larger room is then to be seen as a necessity. Individuals that we spoke to told us they are satisfied with their rooms and there is scope to personalize these if they wish as we saw was the case. The home has a number of toilets that are fairly close to all bedrooms with an adapted bath available in the bathroom downstairs for individuals unable to use a standard bath. We discussed the homes heating system with the provider as there have been known to be some difficulties with the temperature in the older part of the building, although this was not noted at the time of our visits. The provider told us that the heating system is still to be overhauled so as to improve its performance. When asked individuals did not raise any issues with the temperature within the home. we saw that the home was generally clean and tidy at the times we visited. Whilst we received comments as to the cleanliness of the building via complaints since the last inspection more recent comments we received from residents and relatives tell us that the home is now clean and fresh smelling. We recieved some limited comment as to occassional odours in the lounge, although noted none during the time of our visits, despite spending time in this room. Care Homes for Older People Page 22 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are now available in sufficient numbers to support the people who use the service, and whilst there are gaps in training these are mostly identified and training needs are been sourced so as to ensure staff have access to the appropriate skills and knowledge. The homes recruitment practices protect individuals living at the home. Evidence: People told us that they are satisfied with the response received from the permanent staff employed at the home to care for them with comments such as staff are very kind, Staff are always presentable and available to the needs of our relative and The staff are always caring towards residents. There have been some concerns expressed in regard to the turn over of staff and the reliance on agency staff to fill the gaps left due to this over the last 12 months however, this a matter that the provider did advise us of at the time. Based on what we saw at the time of the inspection this situation has improved with the staffing rotas showing less of a reliance on agency staff and an increase in the permanent care staff employed. We have also received comments as to staff been rushed during the day this again another possible outcome of the issues that the home did have with staff turnover, and extensive use of agency staff. At the time we visited we judged there to be sufficient care staff available to meet the current needs of the resident group, although the sickness of the cook on the one day did Care Homes for Older People Page 23 of 32 Evidence: prevent some difficulties. Discussion with some of the staff indicated that there has been improvement in respect of staffing arrangements of late. The turnover of staff obviously has the potential to impact on the providers ability to maintain a reasonable level of training amongst the staff team. Despite this, and as we saw from sight of staff training records and the homes training plan, the impact has seemingly been reasonably managed. There are some areas where training input is needed although we did see evidence that sessions have been arranged in such as moving and handling, infection control and dementia care. The provider told us that training in first aid and abuse will be sourced as soon as possible. We noted that there was no evidence that staff had training in use of the hoist, this a matter the provider said they would discuss with the moving and handling trainer. It was pleasing to see that the home has over 50 of staff with a vocational qualification in care and there is an emphasis on training staff to a minimum of NVQ level 2. The home was seen to have a satisfactory recruitment procedure that meets statutory expectations and examination of the files of three recently recruited staff shows that the home employs staff in accordance with its procedures and so as to promote the safety of residents. We saw that the home has an induction pack that follows national training organization standards, this provided to newly employed staff as evidenced by sight of completed records and discussion with some of the staff team. There was one instance where this was not applied, this where the new employee was promptly enrolled on NVQ 2. We noted that there was a pregnant employee who in discussion told us that they had discussed relevant risks with the provider, this not however documented as should be the case. Care Homes for Older People Page 24 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Fluctuations in day to day management have caused some uncertainty over the last 12 months although management and administration of the home is now more stable and sharing of responsibilities amongst the staff team more equitable. The home has developing quality assurance systems that are expected to improve the quality of the service. Evidence: The home does not currently have a registered manager but is been managed on a day to day basis by the homes provider Mrs S Odedra. We have been told that she intends to manage the home as the manager for at least another year and has been advised to seek registration as the manager in addition to her existing registration as a provider. Due to the fact she is now in the management role she has enrolled for the appropriate management training. Her direct experience of management of the home, and the improvements that we have seen over the last year as well as response to some difficulties has shown us that she is improving her skills and knowledge in this Care Homes for Older People Page 25 of 32 Evidence: area. It is clear that further experience and training would assist her to improve her management skills. We have noted that she has demonstrated a willingness to learn and improve as well as work co-operatively with us and other statutory agencies. There have been difficulties encountered earlier in 2008 with only one permanent senior employed at the home at one point. This matter has been addressed through robust recruitment and selection of seniors so that there are now sufficient in post to share the workload. Senior Staff told us that the matters have improved and the pressure on any given individual has now lessened. The homes systems for quality monitoring we saw are developing and the provider gathers the views of residents and staff through meetings and questionnaires. Questionnaires have also been sent to relatives. Comments from these we saw are positive overall. We saw that the provider is starting to introduce systems for audit which should help identify issues before they become problematic. In discussion the provider told us where there was need for improvement and is honest as to what are barriers to the service, including recognition of where there are gaps in her knowledge and experience. The Annual Quality Assurance Questionnaire that was sent to us prior to our visits was well completed and accurate based on what we found. From sight of a number of staff files we saw that the provider has commenced providing staff with one to one supervision quite recently, records of the same well documented and signed by both parties involved. The provider told us that she will continue this practice and also intends to appraise staff in the near future. The adoption of a schedule for the planning of supervision of staff would be advisable. We looked at policies and procedures in respect of how the home protects residents valuables and found these to be acceptable. We also sampled some of the residents monies in safe keeping and found accurate and well documented records that reflected the monies safe kept. In respect of inventories of individuals properties we did however find room for improvement as these are not always completed and when they are there are gaps (as we noted jewelery a person was wearing was not recorded on them). The home was seen to have a clear health and safety policy although there have been some difficulties in respect of food safety that resulted in the home only receiving one star after their last food safety inspection early in 2008. We saw that the provider has worked hard to address a number of these issues however and have been informed by Environmental Health that they are making good efforts to improve. The monitoring arrangements in respect of safety are improving with use of such as risk assessments and fall audits to highlight any trends in respect of accidents in the home. We noted that there have been some accidents where residents have been found on the floor Care Homes for Older People Page 26 of 32 Evidence: and whilst we were told that residents assisted staff to lift them, the records did not state this was the case, and the staff must be aware that they must not physically lift individuals off the floor. The home has a hoist that could be used however - and risk assessments for individuals must reflect the actions to be taken in these instances so as to protect residents and staff. We have been sent notification of most incidents that the provider has a legal duty to notify us of, although we noted there was one that was missed. Care Homes for Older People Page 27 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 The registered provider 31/01/2009 must discuss the arrangements for administration of as directed medication with the prescriber so that it is clear as to the frequency these medications must be given. This is to ensure that staff are clearly aware of the regime for administration of medications. 2 19 23 The registered provider 09/01/2009 must ensure that attention is paid to joints in carpets to ensure tripping hazards do not develop. This is to ensure that there is no risk of individuals tripping over worn carpet. 3 30 13 The registered provider must ensure that all staff have training in lifting residents with the homes hoist. 30/04/2009 Care Homes for Older People Page 29 of 32 This is to ensure that when residents are transferred with the hoist this is done so safely 4 35 17 The registered provider 31/01/2009 must ensure that inventories of residents property are routinely completed for all individuals living at the home, and that they are accurate. This is to ensure that individuals property is protected Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The registered provider should ensure that the statement of purpose contains information on the fees for residency at Everley and sizes of all bedrooms so as to assist with prospective residents decisions to move into the home. The registered provider should ensure that contracts carry information as to all services that are not included in the fee for residency at the home. The registered provider should look to developing strategies for communication where communication plans identify issues. The use of flash cards with clear visual images and development of communication passports should be commenced. The registered provider should ensure that the weights of residents are monitored consistently on a regular basis and use of a tool to check peoples BMI rating is considered so that it is known when weight gain/loss is to be identified as a possible risk to an individuals health. The registered provider should look at alternative methods of monitoring weight loss/gain through such as limb measurement, this where residents cannot be physically weighed. More advice can be obtained from dieticians at the Primary Care Trust. 2 2 3 7 4 8 5 8 Care Homes for Older People Page 30 of 32 6 14 The registered person should ensure that risk assessments are carried out to decide as to the limits of individuals mental capacity (in accordance with the Mental Capacity Act guidelines); and then clearly document all limitations that may result when carrying out their personal care so this is in a way that considers their best interests against their stated wishes. This is to assist individuals to exercise personal autonomy and choices wherever possible, and where not possible to ensure that their best interests are represented. The registered provider should document any informal concerns and their response to these as a matter of routine good practice. The registered provider must ensure the current contact details for the CSCI (the national helpline number) and social services are contained within the homes complaints procedure. The registered provider should consider the purchase of a wheelchair ramp for use at the main entrance to the home as they suggested . The registered provider should keep a rooms suitability for meeting an individuals needs under review dependent on any risk presented due to their physically ability, and their express wishes. The registered provider (who is acting as manager) should apply to the CSCI for registration as the homes manager. The registered provider should ensure that staff are instructed to ensure that no residents are manually lifted from the floor in the advent of accident. The approach to such needs to be risk assessed for each resident on an individual basis. Where residents lift themselves from the floor this needs to be clear in accident reports 7 16 8 16 9 19 10 23 11 12 37 38 13 38 The registered provider should ensure that all matters relating to Regulation 37 events are brought to the attention of the CSCI. The registered provider should ensure that all potential risks for pregnant employees are confirmed through a documented risk assessment. 14 38 Care Homes for Older People Page 31 of 32 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 32 of 32 - 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!