Inspection on 13/06/07 for Eversfield

This inspection was carried out on 13th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eversfield 20/10/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Eversfield 56 Reigate Road Reigate Surrey RH2 0QP Lead Inspector Sandra Holland Unannounced Inspection 13th June 2007 10:30 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 Eversfield DS0000064751.V339414.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. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eversfield Address 56 Reigate Road Reigate Surrey RH2 0QP 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) 01737 229899 01737 229898 eversfield@efhl.co.uk Elizabeth Finn Homes Ltd Ms Ann Reid Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2005 Brief Description of the Service: Eversfield is owned by Elizabeth Finn Care and managed by Elizabeth Finn Homes Limited and is one of a number of care homes managed by the organisation. The home is a large converted house situated in Reigate, Surrey which has been extended to accommodate up to 35 people in single bedrooms with ensuite facilities. Three additional resident rooms have been created since the last inspection and are included within the recent, new registration of 35. The service provides an elegant and comfortable environment and there are extensive, well-maintained gardens and grounds. Car parking is available within the grounds. The fees at this service range from £640.00 to £705.00 per week. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulation Inspector carried out the inspection over eight hours. The Head of Care was present representing the service. A full tour of the premises was carried out and a number of records and documents were sampled, including care plans, medication administration records (MAR), and staff files. Twelve residents, seven staff, one visitor and one visiting healthcare professional were spoken with during the course of the inspection. An Annual Quality Assurance Assessment (AQAA) was supplied to the home and this was completed and returned. Information supplied in the AQAA will be referred to in this report. The AQAA states that a Resident’s Charter is in operation in the home to promote equality and diversity, and that staff work within this guidance. People living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank residents and staff for their time, hospitality and assistance. What the service does well: The home is an elegant building and is very well decorated and furnished to a high standard. Attractive and well-maintained gardens and grounds surround the home. All areas of the home were very clean, well presented and appeared hygienic. Residents are supported by a full team of staff, many of whom have worked at the home for a number of years, which ensures consistent care. Staff were seen to treat residents in a friendly manner, whilst maintaining respect. Staff recruitment is effectively carried out and the home meets the recommended target for staff trained to National Vocational Qualification (NVQ) level 2 or above. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents must be assessed before they move into the home, to ensure the home can meet those needs. EVIDENCE: The files of a number of residents were seen, including those of recently admitted residents. The needs of some recently admitted residents had been assessed before they moved into the home, but not for others. For one resident their needs had been assessed a week after their admission and the needs of another resident had been assessed on the day of admission. It would not be possible for the home to know if it could meet the residents’ needs if an assessment has not been carried out before admission. Staff advised that intermediate care is not provided. A requirement has been made regarding Standard 3, that the needs of prospective residents must be assessed before they are admitted to the home. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ care plans must reflect their current and changing needs and a record of the review of care plans must be maintained. Residents’ healthcare needs are well met and the administration of medication is appropriately managed. EVIDENCE: Staff advised that care plans have been drawn up to guide staff to the care and support needs of residents. The care plans are written and recorded on a computer based system and copies were printed out for the inspector to review. It was noted the care plans recorded the date of any recent changes but did not record all the dates of any previous reviews. Staff advised that these are reviewed “as required”, but “are not required very often”. The National Minimum Standards for Older People (NMS) recommend that care plans are reviewed at least once a month and are updated to reflect current and changing needs. A requirement was made following the last inspection, that Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 10 care plans must be revised to show that a review of care has taken place. A timescale of 11th November 2005 was given but this has not been met. It was also observed that the care plans were not written in a “person centred way”, which is from the residents’ point of view. The section of most of the care plans relating to hygiene states “clean towels weekly”, not as required or requested, which does not reflect residents’ wishes or preferences. It was clear that the care plans have not been drawn up from the preadmission assessments, as recommended by the NMS. A health condition referred to in a pre-admission assessment was not referred to in the resident’s care plan. For another resident, their pre-admission assessment refers to them administering their own medication, although the relevant section of their care plan states, “ensure medication is administered and recorded”. Each resident bedroom has been equipped with an electrically operated bed, to make it easier for residents to move themselves and for staff to assist residents. It was noted that the risks associated with the use of this electrical equipment had not been assessed. A visiting healthcare professional was spoken with during the inspection and advised that recommendations made regarding care or treatment are carried out, and that timely referrals are made if changes are noted in the health of a resident. Records indicated that other healthcare professionals, including general practitioners (GPs) and a chiropodist are also involved in the support of residents. Staff advised that medication is supplied to the home by a national pharmacy chain and the majority of medication is supplied in “blister” packs. These are designed to enable staff to monitor the amount of medication held and to see at a glance if doses have been omitted. The amounts of medication held were checked with the records held and these accurately matched. Medication was seen to be appropriately stored and a fridge was provided for medication requiring chilled storage. It was positive to note that the medication procedure was included in the medication record file and detailed information about each resident was also recorded. It was positive to note that handwritten entries onto the medication administration record (MAR) charts had been checked and signed by two members of staff. Staff were observed to treat residents with respect and to promote their privacy. Staff offered support with personal care discreetly and knocked on residents’ bedroom doors and waited for a response before entering. Requirements have been made regarding Standard 7, relating to care plans and risk assessments. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents need to be consulted about their preferred social activities and arrangements need to be made to enable them to take part in local and community activities. Residents are supported to maintain contact with their families and friends and are offered a well balanced diet. EVIDENCE: Information supplied in the home’s Annual Quality Assurance Assessment (AQAA) indicated that a weekly programme of activities is arranged. Residents spoken with had received an activity programme for the week in which the inspection took place, but advised that this was the first programme they had received for a long period. The programme was noted to include activities such as a video, a weekly fellowship meeting, a University of the Third Age (U3A) music session and a prayer and hymn group on Sunday morning. A quiz was held on the afternoon of the inspection and the hairdresser had visited that morning, both as scheduled on the programme. A small “shop” is available in the home for half an hour on two afternoons each week that enables residents to buy cards, stationery, toiletries, sweets and biscuits. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 12 A number of residents said that they feel there are not enough activities arranged and thought this was because there are not enough staff to carry these out. Residents mentioned that they would like to go out into the community more often, shopping or to the bank for instance, or for walks in the garden. Other residents said they had enjoyed the gentle exercise sessions, but these had been stopped. The home has a spacious and wellequipped activities room, but staff advised that there is no activity co-ordinator employed at present, although recruitment to this post was being carried out. The home has its own minibus to take residents out or to appointments, but residents advised that the bus had been out of action for a long period due to mechanical problems, although staff advised that these had now been repaired. Some residents also felt the bus was not available for outings as it was used to take residents to hospital appointments. Residents advised that visitors to the home are made very welcome and a small sitting room can be used to entertain visitors or to invite families or friends for meals. Some residents spoke of inviting their own friends into the home for card or board games. A kitchen is provided on each floor of the home to enable residents or their visitors to make their own refreshments if preferred. Although residents are able to maintain their independence in many ways, such as administering their own medication, there appear to be limitations on other activities. A number of residents advised that they are “told” when they can have their baths and breakfast is served only at 08.30 in the dining room, although residents can have a breakfast tray in their room. Meals are served in the spacious dining room, with a number of attractively laid tables, mostly seating four people. A menu was seen and it was noted that there is a well-balanced variety of meals on offer, including a choice of two main meals each day. Staff ask residents each day what they would like to order for the following day. Other options, including salads, omelettes and filled jacket potatoes are also available. Residents gave mixed reports about the quality of the meals served, with some residents saying they enjoyed the meals in the main and others stating that the meat is of poor quality and is tough. Staff advised that the meat supplier had been changed in order to improve the quality and the menus had recently been revised. From information in the AQAA, it was noted that the home had recently changed from using contract caterers to employing its own team of catering staff. It was also noted from the AQAA that of the four catering staff employed, only one had a current food hygiene qualification. A requirement was made following a recent Environmental Health Officer’s inspection that the Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 13 kitchen staff without a current food hygiene qualification must receive this training. Catering staff advised that specialist diets could be catered for and currently the home was catering for diabetic residents. A vegetarian option is offered each day, although no current residents follow a specified vegetarian diet. A requirement has been made regarding Standard 12, that residents must be consulted about the activities arranged. A requirement regarding kitchen staff training has been made at Standard 30 which relates to staff training. Recommendations have been made regarding Standards 14 and 15. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints policy and procedure is available, although no complaints have been received. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: Information supplied in the AQAA indicated that no formal complaints had been received in the last year and it was the aim of the home to maintain this standard. A summary of the complaints procedure is displayed in the entrance hall and the full procedure is available in the Service User’s Guide, which is also made available in the hall. No complaints have been received by CSCI for this service. Residents spoken to advised that they would speak to the manager or person in charge if they had a complaint or were unhappy in any way. A visitor advised that they were not aware of the complaints procedure, but would approach the manager or person in charge if they had any concerns. It was positive to note that a number of very complimentary “thank you” letters and cards were displayed at the staff workstation. These were from past residents or their families, and all were appreciative of the care and support provided. The home’s policy and procedure relating to abuse was seen to refer to the local authority procedure for Safeguarding Adults (formerly Protection of Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 15 Vulnerable Adults). Staff advised that in the event of a suspicion or allegation of abuse, the home would follow the Surrey Multi-Agency Procedure for Safeguarding Adults and an up to date copy of the procedure is held in the home. Staff spoken to stated that they were aware of the types of abuse that could occur and some staff stated that they had received training. Staff said they would inform the manager or person in charge if they had any concerns regarding residents and that the management of the home were supportive and accessible. From the training records seen it was noted that a number of staff need to undertake training in Safeguarding Adults. These staff included care staff, but were mainly ancilliary staff. It is important for ancilliary staff to receive safeguarding training, as they also interact closely with residents and may have unsupervised access to residents, their rooms and their belongings. A requirement has been made regarding Standard 18, that staff undertake safeguarding Adults training. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presented as an attractive and comfortable place to live and was very clean and appeared hygienic. EVIDENCE: Staff advised that the home had been totally refurbished approximately five years ago and it was seen to be very well presented and maintained. The home has been decorated and furnished in an elegant style, with co-ordinating soft furnishings. There is a selection of communal rooms, which enable residents to spend time away from others or can be enjoyed together. These include the main lounge, a library, which is also used for church services, two smaller lounges and a small conservatory on the lower ground floor. A large conservatory is accessible from the main lounge and opens out onto attractive gardens, which were being maintained at the time of the inspection. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 17 A spacious and airy dining room is also available, with French windows overlooking the gardens. As mentioned earlier there is a kitchen for the use of residents or their guests on each floor of the home and staff advised that these are regularly replenished. During the tour of the premises, it was noted that a number of windows on upper floors were not restricted and could be opened fully, and a number of fire doors were wedged open. These present a potential hazard to the health and safety of residents and are referred to at Standard 38, which relates to health and safety. All areas of the home were clean and freshly aired. A laundry is provided on the lower ground floor and this was well equipped with machines with appropriate settings. A member of staff is allocated to laundry duties. In the majority of toilets and bathrooms, paper towels and liquid soap were provided to prevent the spread of infection. It was observed that in the guest toilet and another ground floor toilet, that fabric towels were being used. Staff advised that this was because paper towels had been put down the toilet on a number of occasions and this had caused blockages in the sewerage system. Staff were very well presented in uniforms provided by the home. Staff advised that personal protective equipment, including aprons and gloves is made available and is used, to prevent infection and the spread of infection. Records seen indicated that seven staff have undertaken infection control training. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A full team of staff are employed to meet the needs of residents and recruitment checks are effectively carried out. Staff need to receive a thorough induction into their role and a number of staff need to receive further training. EVIDENCE: From the information provided in the AQAA and from speaking to staff, it was clear that residents are supported by a stable team of staff, some of whom have worked at the home for a number of years. This ensures continuity and consistency of care for residents. Although the majority of the team are care staff, catering staff, housekeeping staff, a maintenance worker, a receptionist and an administrator are also employed. As mentioned earlier, the post for an activities co-ordinator is currently vacant. Information provided at inspection confirmed that nine care staff have achieved a National Vocational Qualification (NVQ) to level 2 and one member of staff has achieved NVQ level 3 in care. Other staff advised that they are working towards their NVQ level 2 and the home meets the recommended 50 of staff trained to this level. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 19 The files of a number of recently recruited staff were seen and all the required recruitment checks had been carried out, including two references for each person and a Criminal Records Bureau (CRB) disclosure. Staff advised that a video system of induction is carried out in the home. Using this system, staff watch a video relating to a specific area of their work, such as the role of the care worker and fire safety and then complete a questionnaire to check their understanding of the information in the video. A Common Induction Standard progress log had been prepared for one member of staff, although no entries had been made in the log. From the staff files seen, it was noted that the induction of staff needs to be improved. For two members of staff who have been employed for six months, only two or three of the induction videos had been covered. Another member of staff had been employed for three months, but there was no record of any induction having been carried out. It is a requirement that induction must be carried out and that a record of the induction must be maintained and kept in the home. A record of staff training was seen and it was noted that a number of staff need to receive mandatory and other training appropriate to their role, to enable them to carry out their role safely and effectively. As mentioned previously, three of the four catering staff need to undertake training in food hygiene and a number of care and ancillary staff need to receive training in Safeguarding Adults, fire safety, health and safety and manual handling. The training record indicates that manual handling training was last undertaken in 2004, although this should be updated each year. Housekeeping and maintenance staff also need to receive training to effectively carry out their role and to safeguard them. None of these staff have received training in the Control Of Substances Hazardous to Health (COSHH), even though they use these substances in their daily work. These staff also need to receive training in manual handling and health and safety. Other than kitchen staff, the staff group is totally female and predominantly of British origin. This reflects the residents group, in that the majority of residents are female, and all are of British origin. Requirements have been made regarding Standard 30, that staff must receive induction and a record of the induction must be kept in the home and that staff must receive training appropriate to their role. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 20 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, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home needs to be more robust to ensure that residents receive the required standard of care and support and that residents’ health and safety are promoted. EVIDENCE: The registered manager was on annual leave at the time of the inspection and the deputy manager capably provided the information and assistance required. The deputy advised that she had worked at the home for thirteen years as a care assistant, was promoted to acting head of care a year ago and had recently been appointed to her current role. The deputy manager was well organised, knowledgeable about the residents and managing the home and displayed a commitment to providing a high quality of service at the home. It was noted that throughout the inspection, Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 21 the home was calm and well ordered. A number of actions were taken immediately, the deputy manager advised, to address the shortfalls noted below relating to health and safety. The number of outcomes for residents which are adequate and one which is poor, indicate that the home needs to be managed in a more robust way, to ensure that these standards are improved. The deputy manager stated that she did not know when the last quality assurance survey was carried out, to obtain the views of residents and others on the quality of the service provided. It was agreed that this information would be obtained and forwarded to CSCI. A number of residents advised that residents’ meetings have not been held in the home for a long period. Many expressed the wish to have the opportunity to discuss their views, particularly regarding food and activities. Residents were aware that a catering comments book is available and advised that they have used this to make both positive and negative comments. The information provided in the AQAA stated that there is continuous liaison with residents and their families, particularly in relation to catering and housekeeping. It was also stated in the “What we could do better” section of the AQAA, that the home needed to “Implement regular programme of formal Residents Meetings to encourage regular feedback”. This is strongly recommended, to ensure residents are provided with the opportunity to meet with the home’s manager, to air their views and take part in decision making within the home. The administrator advised that monies are held for safekeeping for a number of residents. To safeguard residents’ finances, only the administrator or senior staff have access to these and two signatures are recorded for each transaction. The amounts held were checked with the record held and these accurately matched. Residents are also provided with a lockable facility in their bedrooms, in which to store any valuables. During the tour of the premises it was noted that a number of windows on upper floors of the home, were not fitted with restrictors to prevent them opening fully, and there were no safeguards to prevent anyone from falling. It was also noted that a number of residents’ bedroom doors were wedged open, although they had been fitted with automatic closing arms. These are fitted to ensure that the doors close automatically and in the event of a fire, prevent the spread of fire and help safeguard residents. Residents would not be safeguarded if the doors are wedged open. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 22 An immediate requirement was made at the time of inspection, that all windows where there is a risk of anyone falling, must be restricted to prevent falls, and doors designed to close automatically must not be wedged open. A number of residents’ bedrooms on the lower ground floor have doors opening onto the garden. It was observed that a resident had gone upstairs to lunch, leaving the doors to the garden open. This poses a possible risk to the security of the premises and the safety of residents and staff, and it is recommended that the security of the building should be reviewed. From information supplied in the AQAA, it is clear that the required maintenance and checks on systems and equipment in the home, are carried out to the required frequency, to promote the safety and welfare of all who live and work at the home. Health and Safety at Work posters were displayed in a number of locations in the home and the home’s insurance policy was displayed as required, in the entrance hall. Requirements have been made regarding Standard 31, that the home must be managed and conducted to promote and make provision for residents’ health and welfare, and Standard 33, that the results of any survey of the quality of the service provided are supplied to residents and CSCI. Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 23 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 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 2 Standard OP3 OP7 Regulation 14 Requirement Timescale for action 13/07/07 17/08/07 3 4 OP7 OP7 5 OP12 6 OP30 7 OP30 The needs of residents must be assessed before they are admitted to the home. 15 Residents’ care plans must record that a review of the care provided and a review of the care plan, have been carried out. Timescale of 11/11/05 not met. 15 Care plans must reflect the assessed, current and changing needs of residents. 13 (4) (c ) Assessments of any risks to residents must be carried out, including the risks associated with the use of electrical equipment such as electrically operated beds. 16 (2) Residents must be consulted (m) about their social interests and arrangements must be made to enable them to take part in local, social and community activities. 18 (1) (c ) Staff must receive induction (i) training and a record of their induction must be maintained and kept in the home. 18 (1) ( c) Staff must receive mandatory and other training appropriate to their role. DS0000064751.V339414.R01.S.doc 17/08/07 13/07/07 17/08/07 17/08/07 14/09/07 Eversfield Version 5.2 Page 25 8 OP31 12 9 OP33 24 The registered persons must ensure that the home is managed and conducted so as to promote and make proper provision for the health and welfare of residents. The results of surveys into the quality of the service provided must be supplied to residents and CSCI. 14/09/07 14/09/07 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 OP15 OP33 Good Practice Recommendations It is recommended that residents are consulted about the meals provided and their views are considered when planning the menu. It is recommended that resident’s meetings are held on a regular and planned basis to enable residents to discuss the running of the home. It is recommended that the security of the premises is reviewed to ensure the safety of residents and staff. OP38 Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Eversfield DS0000064751.V339414.R01.S.doc Version 5.2 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. 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