Inspection on 13/04/07 for Eversleigh

This inspection was carried out on 13th April 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Eversleigh 06/04/09

Eversleigh 05/07/06

Eversleigh 30/11/05

Eversleigh 27/04/05

Eversleigh 29/11/04

Eversleigh 10/05/04

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 Eversleigh Eversleigh 13 Sundridge Avenue Bromley Kent BR1 2PU Lead Inspector Ann Wiseman Unannounced Inspection 13th April 2007 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 Eversleigh DS0000006914.V336325.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. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eversleigh Address Eversleigh 13 Sundridge Avenue Bromley Kent BR1 2PU 020 8464 2998 020 8464 2998 eversleigh@cnvltd.wanadoo.co.uk 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) C.N.V. Limited Mrs Elizabeth Davies Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 24 Elderly persons of either sex Date of last inspection 5th July 2006 Brief Description of the Service: Eversleigh is a large, three-storey. Victorian-style house, converted for residential living, providing care and accommodation for older people. The home is set in well-maintained gardens, with some off-road parking to the front. Resident’s accommodation is on the two lower floors accessed by a passenger lift and a stair lift. Central heating is provided to all areas of the home. There are grab rails and handrails on stairs, in passageways, toilets and showers. Bathrooms are fitted with specialist bathing and toilet equipment, lifting aids are also available. All bathrooms, toilets, showers and bedrooms are fitted with a lock, which is accessible from the outside in case of an emergency. There is a telephone accessible and available to the residents, and several of the residents have one at their own expense. The home is maintained to a good standard. Work has begun on developing the top floor into five extra rooms with living areas and kitchen. The work is being finished to a high standard and should be a nice living area when finished. Despite all the work that is in progress the Service Users are not being unduly inconvenienced and care is being give to Health and Safety Issues. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Inspection included a six-hour site visit that was facilitated by the Registered Manager. During the visit the Inspector was given a tour of the building and was able to talk to some of the people living in the Home and a few of the staff members. The Commission send Questionnaires to the Residents and their families. The building was clean and well presented and there is a high standard of décor and furnishing, some of which has been renewed and replaced since the last Inspection. The Manager was open and helpful and during the day it became evident that she has a god understanding of the needs of the people living in Eversleigh and there was an easy atmosphere in the home, the Manager has a good rapport the Residents and there was a lot of easy banter between the people living in the home, the staff and the manager. All files that were examined were well ordered. The staff members that were spoken with appeared to be knowledgeable about the Service Users needs and the running of the home. People living in the home said that they received a good service and that they liked living at Eversleigh; the staff are kind to them, the food is of a good standard and they are always offered an alternative menu, the rooms are comfortable, well decorated and personal to everyone. What the service does well: What has improved since the last inspection? Some new furniture has been provided in the communal areas and the dinning room chairs have been recovered to match. A new Handy Man has been employed since the last inspection who seems to have settled in well and the ongoing maintenance program is keeping the home looking fresh and well looked after. The home has also employed an activities coordinator who has some imaginative ideas for activities that Residents say they enjoy taking part in. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 6 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. Eversleigh DS0000006914.V336325.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 Eversleigh DS0000006914.V336325.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): All of the above standards were judged on this occasion. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People enquiring about moving into the home are given enough information to make an informed decision about it, Residents are given a contract and their needs are assessed and assurance is given that the home will be able to meet their needs prior to them moving in. EVIDENCE: The house has a Statement of Purpose and a Residents Guide that is comprehensive, it is given to all new people when they move in and a copy is also displayed on the table in the entrance hall. A waiting list is kept and prospective residents are invited to tea and if they chose to move in it will be on a month’s trial. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 9 The manager will visit the person at home or hospital prior to admission to make an assessment and will also consult with care managers, nursing staff and relatives for further feedback. A review meeting will be held before the placement becomes permanent. This home does not offer intermediate care. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 10 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): All of the above standards were examined during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are detailed and Residents have their health needs met. Medication is handled in an appropriate way. Rights and privacy are upheld. Seeking peoples choice and feelings around death and dying is not fully addressed. EVIDENCE: Three peoples Care Plans were examined in detail and they were found to be informative; each plan carries a short life history of the person as well as personal details and preferences. The home does consider risks and draws up guidelines to manage it, but don’t always do risk assessments in a formal way or record outcomes. The Manager and Inspector discussed the importance of keeping a paper trail to show why and how risks were assessed and interventions are implemented. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 11 The Manager has undertaken to devise a risk assessing system and to keep records of the process and its outcomes. Please see Requirement 1 All of the people living in the home are registered with a doctor and there was evidence on the files examined that they have access to specialist treatment as needed. Doctor’s visits are recorded, as are hospital appointments and their outcome. One person attended a diabetic clinic and another was supported to seek eye treatment. Medication was examined and found to be in order, there were no mistakes and the member of staff on duty displayed a good knowledge of the medication and it’s proper administration. There was written evidence that there had been a medication review for all of the Residents recently. People living in the home voiced content, said that they are treated with respect and that their right to privacy is upheld. On admittance the home will ask the new Resident to tell them what arrangements they have made in the event of their death but the records are not very detailed, mainly only recording if the person wants to be buried or cremated. Often the space is blank. Residents should be encouraged to express their wishes about what they want to happen when death approaches and to provide instructions about the formalities to be observed after they have died. A Requirement will be made that the Manager develops a system that enables staff to sensitively gather detailed information about the care people living in the home would like to receive at the end of their lives. Some of the topics covered should include whether a resident wants to be taken to hospital or to stay at home when they become seriously ill or close to death, also they should be asked to consider if they wanted to be resuscitated in the event of their heart stopping, or if they had any special requests for treatment in the last days of their lives. Encouraging discussion around this area will help reassure people that at the time of their death staff will treat them and their family care, sensitivity and respect. Please see Requirement 2 Staff members receive training in dealing respectfully and sensitively with death and bereavement. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 12 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): All of these standards were assessed on this occasion. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Residents and their families feel that the lifestyle in the home matches their expectations, preferences and satisfies all their needs. A varied program of activities is offered and contact is maintained with friends and family, Residents are helped to exercise choice and control over their lives. Food offered is varied and wholesome and is served in pleasant surroundings. EVIDENCE: The people the Inspector spoke with and those who replied to the user survey all expressed satisfaction, saying that the home addressed their needs socially, culturally and offered religious support if requested. The home has recently employed an activities co-ordinator; she was employed by the home in another capacity at the time of the Inspection and was working part time in her new post until a replacement is recruited for her old one. The Manager reports that she is keen and enthusiastic and there was evidence that people living in the home were taking part in the activities offered; Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 13 People have been painting in watercolours, plotting their family tree, designing Easter bonnets and flower arranging. The co-ordinator plans to work individually with people who can’t or prefer not to leave their rooms as well as with others in small groups. Contact with family and friends is encouraged by the home and visitors are welcome at any reasonable time of the day. People living in the home talked of visits they received and said that their visitors were made welcome. All those asked felt that the staff allowed them to make choices and decisions for themselves and were happy with the level of control they held. The food served during the Inspection looked appetising and was presented in a pleasing manner. Residents can chose where they want to eat, either in the attractive dinning room or in their own room as preferred. Copies of the menu show a wide choice of food, there is always an alternative offered at each meal and the cook visits each person to take orders for that day, if anyone has a special request the cook will endeavour to supply it. The fridge and larders were well stocked and the kitchen was clean and well ordered. Eversleigh DS0000006914.V336325.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): All of the above standards were inspected during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Eversleigh feel that their complaints would be taken seriously and felt confident that they knew who to speak to if required. The home does not manage anyone finances and all resident’s legal rights are protected. Staff receive training on Adult protection and whistle blowing. EVIDENCE: The home has not had any complaints since the last Inspection, nor has the Commission received any regarding Eversleigh. The home has practice and procedures in place to deal with any complaints and the people asked said that they were confident that if they needed to complain it would be taken seriously and dealt with. The Manager has assured the Inspector that Residents would be given access to legal advice if requested and that she would facilitate advocacy services if they could not act form themselves and had no family to speak on their behalf. The recruitment process is designed to protect the Residents from abuse by making required checks, files that were examined showed that those checks have been made; CRB checks are carried out and references are taken up prior to employment. Staff are offered protection of vulnerable adult and whistle blowing training. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 15 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): All of this area was examined on this occasion. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The environment of this home is safe and well-maintained, communal areas are comfortable and clean and suitable specialist equipment is supplied. Bedrooms are personalised and comfortable, people living in the home have their own possessions around them. The entire home is clean, pleasant and hygienic. EVIDENCE: The home is set off the road in pleasant, well maintained gardens, it is well kept and has it’s own maintenance person who keeps the building and decoration to a high standard. The person responsible for maintenance appeared knowledgably in his area and keeps on top of running repairs and will carry out small jobs that are within his range of expertise for the people living Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 16 in the home. He is also responsible for carrying out the Health and safety checks within the house. There are various comfortable communal areas both large and small and some secluded corners that offer quiet areas, there is also an attractive sun room with a large TV and one that has a radio and music system. All of the communal areas are tastefully decorated and there are abundant pictures, flower arrangements, done by the Residents, and ornaments around the building. Some of the easy chairs have been replaced. The new ones are good quality and of a designed that will enable people using them to be able to get in and out of them easily. The dinning room chairs have been recovered to match the new chairs. There are several communal lavatories that are easily accessed and have adaptations such as riser seats and grab rails. All of the bedrooms inspected appeared suitable to the users needs with room to manoeuvre and are attractively decorated and furnished. Some of the rooms contained small items of the Residents own furniture and personal items. The house was very clean and pleasant smelling. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 17 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): All of the above standards have been assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient well-trained staff to meet the needs of the Residents and the recruitment policy and procedure is as required. EVIDENCE: The rota was examined and staff on duty corresponded to those detailed on it, they appear to show that sufficient staff are on duty at any one time to meet the needs of the Service Users. The home has met the criteria of having 50 of the staff with relevant qualifications of NVQ or equivalent. The Inspector examined five staff files, chosen at random, in detail. All were found to have evidence that the homes recruitment procedure is being followed. All staff had undergone a CRB check and provided two references. Files also contained application forms, proof of identity, contracts and photographs. There is a comprehensive training program including Foundation training, POVA, Risk Assessing, Fire safety, First Aid, Food Hygiene, Health and Safety, Safe Handling of Medication, Dealing with Aggression, Diet and Nutrition as well as continuing NVQ 2 and 3 training. Training certificates are held on staff files. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 18 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): All of the above standards have been examined during this Inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Eversleigh is a home that is run efficiently by an experienced and capable Manager who has put the interests of the people who live in the home first. Staff are supervised, policies and procedures are robust and the Health and safety of the Staff and of the people living in the home is promoted and protected. EVIDENCE: The Manager facilitated the Inspection in an open and friendly manner and all staff and Residents asked said she was supportive and caring. Staff felt that they can approach her for help and advice; the Residents said that she listens Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 19 to what they had to say and deal with issues sympathetically and confidentially. People are regularly asked what they think of the service informally and an annual survey is carried out, issues that arise are discussed and actioned if necessary. Policies and procedures are reviewed at regular intervals and take into account changes in legislation. Insurance details are displayed in the entrance and are of a sufficient level. Financial records are kept and a business and financial plan is available for examination. The home does not manager the Residents finances. Supervision is given and recorded and staff members have confirmed that the sessions take place at regular intervals. Random samples of health and safety records were examined and where found to be in order with safety checks being carried out on fire equipment and points being tested weekly. Hoists and emergency lighting were serviced and freezer temperatures are checked and recorded daily. Staff receive Fire and Health and Safety training. Building work is being carried out at the present time and the builders have taken appropriate actions to keep the people living in the home safe from harm in relation to building materials and the work being done in the home. Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 20 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 3 3 3 3 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 3 3 3 3 3 Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13.4b Requirement The Manager shall develop a system that enables risks to be properly assessed and that records interventions and outcomes. Residents should be encouraged to express their wishes about what they want to happen when death approaches and to provide instructions about the formalities to be observed after they have died. This must be recorded on their files and reviewed regularly and referred to as death approaches. Timescale for action 15/08/07 2 OP11 12 15/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Eversleigh DS0000006914.V336325.R01.S.doc Version 5.2 Page 23 - 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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