Inspection on 30/11/05 for Eversleigh

This inspection was carried out on 30th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 13/04/07

Eversleigh 05/07/06

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 30th November 2005 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 Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 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.V266583.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eversleigh Address Eversleigh 13 Sundridge Avenue Bromley Kent BR1 2PU 020 8464 2998 020 8464 2998 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.V266583.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 24 Elderly persons of either sex Date of last inspection 27th April 2005 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. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection; the manager was on duty on the Inspectors arrival at the home, she, and everyone else, was friendly and welcoming. The Inspectors first impression of the house was that it was clean, fresh smelling and well furnished, she was introduced to the residents and was able to chat to them as she was given a tour of the house. Most of them seemed to be in good spirits and there was a good rapport between them and the manager, both She and the residents were joking and laughing at the prospect of them “digging the dirt” on the manager. The Inspector was able to speak privately with two of the residents and had a group discussion with the staff group including the cook and the domestic worker. A cross section of the records were inspected; care plans and the safety systems and found them to be organised and in good order. What the service does well: What has improved since the last inspection? What they could do better: Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 6 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. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 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.V266583.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): During this visit the Inspector looked for evidence for standards 1-6 and found that there was sufficient information in place to enable prospective Service Users to be able to make an informed choice about where to live and that all other standards were being practiced. EVIDENCE: The house has a Statement of Purpose and a Service Users Guide that is comprehensive, which is displayed on the table in the entrance hall for all to see. 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 basis. 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 house does not offer intermediate care. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Evidence was found to be able to judge all the standards in this area. The individual care plans are comprehensive and covered health, personal and care needs. The Residents have access to the Doctor and the district nurse offers treatment at the house. The staff spoke to the Residents in a respectful way and it is the home’s policy to care for people that are ill or dying in the home unless the care is out of the capabilities of the staff group. EVIDENCE: Six of the residents care plans were examined; those looked at coved all the necessary areas as laid down in regulation 15, each of the resident’s health needs were set out. One of the residents had been found to have MRSA and appropriate treatment was being offered to her. While the Inspector was talking to one of the residents he expressed a desire to hold pain killers in his room so that he could take them as needed, he felt that by having to ask for them from the staff and to wait for them to be dispensed he was being treated as a child. The Inspector was able to negotiate with the manager who agreed that after she had done appropriate risk assessments and she had received an undertaking from the resident in writing to keep them safely stored, he would be supplied with a packet of pain killers Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 10 and would request a new one when needed, this way the staff would be able to monitor the use of the medication by recording the supply of them. Residents that the Inspector spoke with all felt they were treated with respect and had no complaints about the service they received. Whenever a staff member was observed entering a room they knocked on the door and waited for a response before entering, as did the manager during the tour of the building. The manager and staff members assured the Inspector that if a resident was ill or near death they would always care for them at home as long as they could without them needing specialist care. Staff are offered training around the death and dying and felt they were well supported by colleagues and the manager at this difficult time. If a resident dies while a staff member is off duty the manager will phone and tell them of the event before they come on duty again. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were judged, residents receive contact from family members and friends, menus offer a range of meals for the Residents to choose from and it looked well prepared and wholesome. EVIDENCE: The care plans and assessments explored lifestyle options and preferences as well as stating background information for each person, One residents is Jewish and her dietary preferences are always respected. One of the Residents told the inspector that she often saw her daughter who would take her out for lunch on occasion, other Residents talked about family visits. The dinning room was bright and inviting with the tables attractively laid. Water was freely available from a water cooler and each table had a menu that listed the day’s meals. There was an extensive choice of main dish and each meal offered three courses. When it was served the food it looked inviting, was well presented and was of sufficient quantities. If preferred Residents eat in their room. On examination the larder and freezers held a wide variety of food in sufficient quality and quantity to assure all would be well fed. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 12 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): Standards 16 and 18 were looked during this inspection and evidence was found that if a Resident or their family wanted to make a complaint there was sufficient information available to inform them what to do and who to contact. Staff files showed that all new staff members have all required checks carried out to help protect the Residents from abuse. EVIDENCE: On inspection the complaints procedure proved to be detailed and contained details of the complaints procedure, names and addresses of those that can be contacted in the event of a complaint including the Commission. The Residents who spoke to the Inspector felt confidence that if they made a complaint it would be dealt with quickly and fairly. Staff members informed the inspector that they would always report complaints made to them try to deal with it if possible and that they would inform the manager either way. The house has policies that cover possible abuse and staff members have received training on Adult Protection. The staff files show that all new staff members have had an enhanced CRB and POVA check, that two satisfactory references have been sought and received and there is evidence to prove identity. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 13 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): All these standards were covered on this inspection. The house was clean and well maintained; the interior was well furnished and gave a comfortable and homely appearance. The bedrooms were individually decorated and furnished and reflected the residents interests and personality. The gardens are well kept and inviting. There are sufficient well-adapted toilets and bathrooms; some of the room have en suit facilities. EVIDENCE: The house was clean and well maintained to a high standard; the interior was well furnished and gave a comfortable and homely appearance. New sitting room furniture has been purchased and is appropriate for it’s purpose without looking institutional. One of the sitting areas is a large conservatory to the rear of the building, it was warm and had pot plants and pictures around the room. There was a budgerigar in a cage and a music centre and a bookshelf containing CD’s and videos and there was a very large flat screen TV that would be easily seen by Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 14 all. The residents in this lounge said that it was a favoured area. There was a pleasing view of the well-kept and inviting garden from this room. The bedrooms were individually decorated and furnished and reflected the residents interests and personality. There are sufficient well-adapted toilets and bathrooms. Adaptations have been made to some of the rooms to meet the needs of the residents, such as a walk in shower/bath cubical in one of the bedrooms to enable a resident to bath independently. A selection of the health and safety records was inspected and all were complete and up to date. There was evidence that the fire and portable electrical equipment had been checked recently. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 15 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): All standard in this section were examined. There was sufficient staff on duty to meet the needs of the Residents, the training records showed that they have access to a varied and relevant training program and records show that they have been recruited appropriately. EVIDENCE: When the inspector arrived there was sufficient staff on duty to meet the needs of the Residents, whenever staff members talked to or assisted the residents it was done with respect in quiet and caring way, there was obviously a good rapport between staff and residents. The inspector looked randomly at five of the staff files, on inspection they were found to be well ordered and contained all the information required to be keep in the home and was of a quality that lead the inspector to believe that the residents were in safe hands. All staff files contained evidence that CRB and POVA checks had been carried out and that good quality references had been obtained and that they were often verified by phone. All the training records showed that staff have access to a varied and relevant training program and there was evidence that regular supervisions took place these two issues were substantiated by the staff I spoke to. Staff members have to deal with a lot of illness and dying as part of their job and all I talked with felt that they had had sufficient training in this area and that they were well supported during and after these difficult times. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 16 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): The Manager has been in post for many years and it is obvious from the interaction observed that she is popular with the Residents and respected by the staff. There was good-natured banter between her and the Residents during the tour of the house. Practice and procedures inspected showed that the Residents rights and best interests are safeguarded. EVIDENCE: The manager has obtained both the Registered Managers Award and NVQ4 in care and had all necessary checks made to ensure that she is a fit person to manage this home. She appears to get on well with the Service Users and from discussions with the inspector it is evident that she has a realistic and caring attitude to meeting the needs of the residents. Monies held in the care of the manager were checked and found to be order, the house does not manage the Residents finances, family or other representatives will do that and bring in only what money is needed for Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 17 everyday expenses to the house, anything that is needed between visits will be put onto the account if there is insufficient money at the house to cover the cost. The inspector was assured that Manager and Assistant Manger monitor work practice within the home and there is a system of care workers being monitored by senior care staff and all new staff work closely with experienced staff until they are judged competent to work alone. All new staff members work a probationary period and have regular work evaluation meetings. There was evidence on file of regular supervision meetings taking place as well staff meetings and this was substantiated when the inspector spoke with the staff group. All polices and procedures inspected are written in a way that promotes and safeguards the resident’s rights and best interests. A selection of the health and safety records was inspected and all were complete and up to date. There was evidence that the fire and portable electrical equipment had been checked recently. Eversleigh DS0000006914.V266583.R01.S.doc Version 5.0 Page 18 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.V266583.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action 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.V266583.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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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