Inspection on 27/04/06 for Eversfield House

This inspection was carried out on 27th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 House 31/08/07

Eversfield House 06/10/05

Eversfield House 11/08/05

Eversfield House 10/02/05

Eversfield House 14/10/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Eversfield House 45 Mulgrave Road Sutton Surrey SM2 6LJ Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 27th April 2006 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 Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 House DS0000007172.V291306.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Eversfield House Address 45 Mulgrave Road Sutton Surrey SM2 6LJ 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) 020 8642 6661 020 8642 6747 Sutton & Cheam Elderly People`s Housing Association Mrs Bernadette Quinlan Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Eversfield house is a registered charity owned and run by Sutton and Cheam Elderly Peoples Housing Association. It has a Board of Trustees and a management Committee. Eversfield House is situated a short distance from Sutton town centre on a quiet residential street. The home compromises of the original detached property, and a 1950’s extension known as Ely Wing. The accommodation is based on the ground, first and second floor. A lift has been fitted into the property to allow easier access to all service users. The communal facilities on the ground floor include a dining room, a large main lounge, a smaller smokers lounge, a small hairdressing room and a large conservatory. There is an enclosed large garden with flowerbeds and a greenhouse to the rear of the property. At the front there is a tarmac driveway with parking for a number of cars. The service users at Eversfield House are generally fit and able, and are free to come and go as they wish. Eversfield House charges for the year 2006/07 is £400 per week. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/7. It was an unannounced inspection that took eight hours. The inspection took the form of meeting and talking with service users, discussions with staff and the deputy managers; a tour of the building; and sampling paperwork that relates to service users and the running of the home It has been a difficult time for the home. The registered manager had been unwell and periodically had time off work. Since June 2005 she had been on extended sick leave and in November 2005 tendered here resignation. The two deputies, one of whom was relatively new in post, have instead fulfilled the manager’s role. The inspector was informed that the home has appointed a new manager who will start work in mid May. In addition the home has been in the process of major building works to improve the facilities at the home. This has involved the building of a new extension with six bedrooms with en-suite facilities. Phase two of the building work has yet to commence with improvements to some of the existing bedrooms so that they also have en-suite facilities. The overall number service users will not increase. What the service does well: The home has a warm, friendly atmosphere. Service users all commented on the care that they were given, with a common phrase being ‘nothing is too much trouble’. In particular, two of the service users spoken to were on their trial period, and both felt that they had been welcomed and that they fitted into the home. Staff also commented on the fact that they had time to do their job and to spend time talking to the service users. Although the home has effectively been without a manager for a year, none of the service users felt that this had affected the level of care that they were receiving. All spoke with affection of the two deputies who they felt were doing a great job. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 6 It is worth commenting that the two deputies undertook the role of managing the home with no prior planning and have done an effective job. What has improved since the last inspection? What they could do better: The home still needs to focus on staff personal files to ensure that all the required information is available; this was highlighted at the last inspection Although from the files sampled it could be seen that much progress had been made in this area, there were still some concerning omissions. One file only contained one proof of identity; there were many references addressed to ‘whom it may concern’ and not completed on the homes reference sheet; and one reference from a previous employer in the care field which just stated the dates that the person worked in that home. The home must ensure that all checks are carried out thoroughly prior to the commencement of employment to ensure the safety of the service users. This Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 7 requirement is outstanding from February 2005 and therefore needs to be addressed for with In addition, the lack of a manager has resulted in a no strategic overview of the service in particular, a quality assurance programme and effective monitoring. Policies and procedures need to reviewed and updated with particular reference to the service users guide and the complaints policy. The home does not conduct Regulation 26 visits; there is no development plan or a recent service users questionnaire; and of some concern, previous requirements remain outstanding namely the storage of chemicals and other substances hazardous to health. A requirement has therefore been made in this regard. 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. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 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 Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is gathered from a variety of sources including the service user, family and other professionals before a decision is made regarding the suitability of the home. There is then a period when service users have the opportunity to visit the home, and finally a review meeting is held to consider the suitability of the placement. It is only at this stage that a final decision is made about the placement. In this way, service users can feel assured that the placement is able to meet their individual needs, rather than they are being slotted into a vacancy. EVIDENCE: Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 10 Potential service users are encouraged to visit the home if at all possible. If this is not possible, then the deputy managers will visit the prospective new service users at hospital or within another home. The aim of these visits is to gather as much information as possible from the service users themselves, family and other professionals. The home then completes their own needs assessment within 24 hours of admission. The inspector was able to view an example of the needs assessment; the home has admitted eight new service users since the last inspection. The needs assessment included information on mobility, medical needs, and dietary requirements. This assessment is then translated into an individual care plan, which outlines the day-to-day care that is to be given. Potential service users are then offered a six-week trial, which is then followed by a review meeting involving all interested parties. A decision is then made about the suitability of the home. The home currently has two service users who were on their trail periods, both discussed the process that had taken place and how they were welcomed into the home. Both service users were very positive about the care that they had received, with one stating ‘you just have to ask…and nothing is too much trouble’. The home has recently adopted a needs assessments and admissions forms book, which enables the deputy managers to check and monitor that all appropriate paperwork is completed before any admission is made. The two deputies do not have any formal training regarding assessments; both had observed the previous manager and have worked with the elderly for some fifteen years. The home does not have emergency admissions, nor do they provide intermediate care for service users requiring rehabilitation. Currently, all the service users are from a White/European background with four males. Of the establishment of twenty-five workers, eighteen are white women; six are black/British women and there is one white male. The deputy managers stated that they fell confident in dealing with issues of diversity, they were able to evidence this recently when a Hindu service users had respite in the home. The home had addressed issues of religion, gender and food. In addition, the home has various aids and adaptations that would assist service users in their daily lives; these include a lift, grab rails and specialist bathing equipment. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 11 The home were able to provide a service user guide, however, it was somewhat out of date and needed to be revised. A requirement has therefore been made in this regard. It addition, it was noted that one of the service users files did not contain a contract. The home needs to ensure that one is provided to the service users immediately, and that all appropriate parties sign it. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged whenever possible to maintain their own health needs. However, assistance is available should they require it. The health and personal care that service users receive is based upon their individual needs. Care plans are reviewed monthly between the key worker and service users to ensure that needs are accurately recorded. EVIDENCE: A number of service users files were checked at random, all had an assessment, which was then translated into a care plan. These care plans were reviewed on a monthly basis by the service user and their key worker, both then signed the document as confirmation of the care that would be provided. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 13 Risk assessments were in place for each service user within the environment of their bedroom; this was reviewed by one of the deputies on a monthly basis. With regard to health provision, service users are able to retain their own GP if local to the area, or to choose another. Most service users are in fact registered with the local GP. Service users have access to domiciliary dentists or opticians should they require. A private chiropodist is available to service users at no charge. Records are kept of all health appointments; the documentation was checked and found to be update. Medication is stored in a locked metal trolley kept within the main office. Only staff that have undertaken accredited training regarding the administration of medication dispense. The majority of medication is provided by the pharmacist in blister packs. There are currently two service users who self-medicate, they store their own medication in their bedrooms in locked drawers. The recording, storage and disposal of medication was checked, and found to be in order. A pharmacist visits the home on a regular basis in order to audit the administration of medication, the last being on 22.9.05, and found to be satisfactory. Over the last two years, the home has made significant improvements in the administration of medication. No omissions or errors were found; and the home has also introduced a photograph system, which acts to minimise the possibilities of errors being made. There is currently one service users who is diabetic, she is able to check her own sugar levels and take medication accordingly. The diabetic nurse now visits every six months to monitor the situation. Service users are able to consult with visiting professionals in private if they wish. The small chiropody room, the service users bedroom or the office can all be used. From observations it was noted that service users do have their privacy and dignity maintained in other ways; staff knock on bedrooms doors before opening them; mail is received unopened; service users all had a range of their own clothes to wear. Service users were able to confirm this, as were the members of staff who interviewed on the day of the inspection. The majority of service users had private telephones lines fitted in their bedrooms. There was also a public telephone, which did allow for privacy. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Service users are offered a range of activities, which they can chose to participate in they so wish, these include regular weekly activities, outings and organisations coming into the home. Service users also have the opportunity and space for quieter times, and can be independent as possible. The importance of mealtimes is recognised by the home, thereby ensuring that service users maintain their health and well being. There is a social element to mealtimes whereby service users are encouraged to take their meals in the dining area EVIDENCE: Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 15 There are a range of weekly entertainments including music, bingo, quizzes and an ‘exercise lady’ who does chair exercises with the service users. The home has recently started a monthly film showing, which has proved to be very popular. There is a hairdresser who comes fortnightly; the inspector was once again able to meet with the hairdresser who was positive about the care provided by the home. The home has approximately six organised outings per year, when they hire a vehicle from community transport. Service users had mixed views about the outings, some were very positive, one service users reported that she keeps asking about the trips and when they will start; others were less enthusiastic, one service users stating that she had travelled all her life and now she just wanted to stay in one place; another stating ‘why bother’. The home asks for suggestions for outings, but recognises that at the end of the day it is the service users choice that is paramount. Forthcoming events include trips to Richmond Park, boat trip and Lavender railway line. The home will be also running their own summer fete and attending a local school concert. Service users were able to confirm that family and friends were able to visit whenever they wished and were always made welcome by the staff. Service users could choose where to receive visitors, and often the home would lay out meals in the conservatory for them to enjoy in privacy. Service users were observed during the inspection entertaining friends and family in their bedrooms and the conservatory. A meal was taken with service users in the dining area; the setting was congenial and relaxed. Service users were generally positive about the meals provided, with an alternative on offer if you did not like what was on the menu. One of the service users did not like the meals provided and stated that ‘he said what he thought about them’. Two of the other service users stated that they did not like spicy food, but would always be offered something else. Service users have their main meals at lunchtime; evening meals tend to be much lighter and simpler such as cheese and biscuits or beans on toast. Dietary requirements can be catered for, such as diabetes. Drinks are available on request, or at perquisite times. Some of the service users have their own drink making facilities in their bedrooms. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general, the home appears to have an ethos of openness whereby suggestions are encouraged and complaints are taken seriously. This in part ensures that service users feel that their views are taken seriously, will be listened to and will be acted upon. There are procedures in place regarding the protection of vulnerable adults, and senior staff have attended training courses so that they are equipped with the knowledge to ensure that service users are protected. EVIDENCE: Service users spoken to at the time of the inspection knew who to talk to if they had any problems or complaints about their care namely the deputies; none were aware that there was a policy, nor did they recall seeing one. The home has a complaints leaflet, which is adequate, although it does need to be updated. A requirement was made at the last inspection regarding a complaints leaflet; this has not been completed and therefore remains outstanding. The home does have a complaints log, which recorded once compliant since the last inspection, which was dealt with satisfactorily. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 17 The home does have a whistle blowing policy and a copy of Sutton’s vulnerable adults procedure. In discussions with staff there was some awareness and understanding of the issues relating to vulnerable adults and what to do should the issue arise, this included relatively new members of staff. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general the home meets the needs of the current service users, it is homely and comfortable; all service users have their own bedrooms and there is some specialist equipment available for those who have mobility difficulties. There is ample communal space so that service users can chose to be with others in the main lounge, or be in quieter rooms. EVIDENCE: Phase 1 of the major building works has been completed, providing six bedrooms with en-suite facilities. During the works disruption was kept to a minimum and service users stated that they quite enjoyed the activity of the builders. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 19 Phase 2 of the building works will be to revamp Ely Wing so that it meets the minimum standards set down in the Care Standards Act 2000. The overall number of service users within the home will remain the same. A previous requirement that the home redecorates the hallway and downstairs toilet has not been completed, and therefore this requirement remains outstanding. Although it is acknowledged that this would be very difficult to complete currently because of the impact caused by the refurbishment. Therefore an extended timescale has been applied to this requirement. All service users have their own bedrooms, with a single bed, wardrobe and chest of drawers. Service users all have keys to their bedrooms and a space provided, usually a drawer that they can lock if they so wish. Not all the bedrooms were viewed, although a selection were chosen at random. Of those viewed, all were naturally ventilated and had domestic style radiators. Furniture was of reasonable quality and domestic in style. Rooms had been personalised by the service users to reflect their interests and with photographs of family and friends. Service users are free to bring into the home any furniture they may wish. There are a number of aids and adaptations evident in the home. There is a call system, a lift, ramps and grab rails. There are also hoists and medi-baths available. From observations it was noted that a number of the service users were increasingly frail and had difficulties with mobility. The home does not have a hoist, and therefore any falls results in the ambulance service being called to assist with lifting. This is not acceptable as it compromises the service users well-being, as they have to wait whilst an ambulance arrives. The deputies informed the inspector that this issue will be resolved, however, until such time that it is a requirement has been made in this regard. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome group is adequate. This judgment has been made using available evidence including a visit to this service. In general, it appears that there are sufficient staff on duty to provide adequate care of the service users; and that there is a skill mix between age and experience. The home needs to ensure that recruitment procedures and policies are robust in order to safeguard service users welfare. EVIDENCE: The management structure of the home is of a manager, two deputies and four senior members of staff. The aim of the home is to have four members of staff on duty in the mornings; with some overlap, a maximum of five in the afternoons and three in the evenings with at least a senior member of staff on duty. In addition, there are two waking night staff. Samples of the duty rota were taken and found that the staffing levels were being met. The home employs three domestic staff and a supervisor; chef and at weekends a kitchen assistant. The home does not use agency staff; instead any vacancies on the staffing rota are either met internally, or by the use of bank staff. This is considered positive in terms of consistency of care for the service users. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 21 Personal files were checked at random. It was noted that in general there was an improvement in this area, with most files containing completed job applications, notes from interview, references, and terms and conditions. However, there were some areas where procedures need to be tightened up further. References were sometimes open letters ‘to whom it may concern’, and in one particular case the letter just stated the dates of employment and gave no other information. One file only had one prove of identification. A requirement therefore remains that the home must ensure that the recruitment practices protect the service users. In addition, a recommendation of good practice made at the last inspection that references should be followed by a telephone call to the referee to confirm the information given remains outstanding. Discussions with staff indicated that there is an induction process in place, whereby new staff ‘shadows’ a more experienced worker for a month before undertaking any work on their own. The deputies were able to provide evidence of a checklist that is used with all new staff which includes reading of policies and procedures, tours of the buildings and of the systems that are in place. Previously there has not been a strong ethos of training in the home; the previous inspection identified one member of staff who had received no training at all in the previous year, This issue has been addressed and there is a lot more training available to staff, and the majority of staff have undertaken the minimum of three days of training since the last inspection which was only six months ago. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. In general in it recognised that the quality of care provided in a home is strongly influenced by the calibre of the manager. Eversfield has effectively had no manager for almost a year. Whilst recognising the positive contributions made by the deputies, the lack of a manager who has overall responsibilities and a strategic overview is evident within the home. EVIDENCE: As the home has been in a state of flux with effectively no manager for a year it has not been possible to assess standards 31 and 32 effectively, which refer to the calibre of the manager and their style and ethos. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 23 The two deputies have taken on the role of being a manager in a very difficult situation; not knowing when or if the manager would return, having to take on tasks that were partly completed or to initiate others. The deputies should be commented for their work, which have given significant improvements in some areas of work, which have been outstanding for a considerable time and in the case of supervision for years. However, the lack of an effective manager with a strategy overview is now being to show and needs to be addressed with some degree of urgency by the new manager. In particular, the area of quality assurance is lacking. There is no annual development plan; policies and procedures need to be updated and reviewed, in particular the complaints policy and the service users guide; requirements from the previous inspection have not necessarily been progressed satisfactorily; and there are no Regulation 26 visits. Documentation was viewed in relation to safe working practices. Fire alarm testes and drill were last completed on the 29.3.06; gas installation on the 28.2.06; electricity testing was last completed in May 1998 (with a ten year certificate). Legionella testing was completed on the 19.4.05, and Portable Alliance Testing was on the 20.3.05 therefore both were effectively out of date. A requirement has therefore been made in this regard Chemicals and other substances hazardous to health located near the staff toilet must be stored away appropriately. This is an outstanding requirement from the previous inspection and was at the last inspection in October 2005. The requirement therefore remains and must be actioned for with. Service users monies were thoroughly checked and there were found to be no inaccuracies. The lack of supervision of staff has been of concern; there has been a requirement in this regard since September 2003. The absence of a manager has further complicated this issue. The last inspection recommended that in the absence of a manager, that the two deputies complete a supervision course for with, and that they undertake the role of supervision. It is very positive to note that the deputies have undertaken training, and have completed supervision with staff. Of the records sampled, staff had had at least one supervision sessions, which was recorded and signed by both parties. Outside the internal management of the home, the lines of communication remain unclear, in that who is responsible for what. A recommendation remains that the Board of Trustees looks into this matter. Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 24 Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 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 2 2 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 2 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 3 3 3 2 Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 26 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 Standard OP1 Regulation 5 and 6 Requirement The service users guide must be updated and made available to all service users. It must contain all the elements required under Standard 1, Care Standard Act 2000 All service users must be provided with a statement of terms and conditions The complaints leaflet must be updated and made accessible to all service users. Out-standing from October 2005 A hoist must be provided which provides the assessed needs of the service users Staff must have all the appropriate checks undertaken before the commencement of employment. Immediate Out-standing from February 2005 A quality assurance and monitoring system must be in place which cover all the elements of standard 33, Care Standards Act 2000 The must ensure that the health DS0000007172.V291306.R01.S.doc Timescale for action 27/07/06 2 3 OP2 OP16 5(3) 22 27/07/06 27/07/06 4 5 OP22 OP29 12(1)(a) 19(1)(a) 27/07/06 27/04/06 6 OP33 24 27/07/06 7 OP38 12(1)(a) 27/04/06 Page 27 Eversfield House Version 5.1 and safety of service users and staff are maintained. a) Chemicals and other substances hazardous to health are removed b) Out of date food must be disposed of c) Legionella and portable appliance testing must be completed 8 OP31 8 and 9 Immediate The home must employ a manager 27/05/06 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 OP31 OP31 OP29 Good Practice Recommendations The role of the house committee should be defined and made clear to all appropriate persons The manager and/or the deputies should attend management meetings Once references for a new recruit are taken up the home should make a telephone contact with the referee to confirm the reference given Eversfield House DS0000007172.V291306.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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