Inspection on 05/07/06 for Eversleigh

This inspection was carried out on 5th July 2006.

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 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 5th July 2006 08:00 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.V294918.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. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 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.V294918.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 24 Elderly persons of either sex Date of last inspection 30th November 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. 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.V294918.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection and started at 8am. The Inspector was able to talk to six staff members, the Manager and several Service Users and two family members who were visiting, also user surveys were given to all the Service Users by the commission. The Home was clean and well maintained and the atmosphere was relaxed and homely. The staff interacted with the Service Users in a friendly and light hearted way and it was obvious that there was a good rapport between the staff and Service Users. All files and practice and procedures that were examined were well ordered and in place. The staff members that were spoken with appeared to be knowledgeable about the Service Users needs and the running of the home. Service Users said that they received a good service and that they liked living at Eversleigh; the staff are kind, the food is of a good standard and they are always offered an alternative menu, the rooms are comfortable, well decorated and personal to each Service User. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 Page 6 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.V294918.R01.S.doc Version 5.1 Page 7 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): All of these standards were judged on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Prospective Service Users are given enough information to make an informed decision about the home. All Service Users 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 Service Users Guide that is comprehensive, which is 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 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.V294918.R01.S.doc Version 5.1 Page 8 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): All these standards were inspected on this occasion Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Care plans are detailed, each Service User is registered with a General Practitioner and medication is handled in an appropriate way. EVIDENCE: Care plans are detailed, each plan carries a short life history of the Service User as well as personal details and preferences. Each Service User is registered with a doctor and have visits from district nurses if there is a need. The home uses a hospital information form that is completed and sent with any Service User who needs to go to hospital. The information given is detailed and would be helpful to the hospital staff. Included on the form is a paragraph about discharge plans asking the hospital to contact the home before any discharge plans are made and reiterating the importance of a detailed discharge and medication sheet being sent back with the Service User so the Home can continue with ongoing care. It is good to see that the home carries on it’s commitment of care by ensuring the hospital has important and detailed information on admission and that it Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 Page 9 asks that the same consideration is given by the hospital on discharge. This an example of good practice. Medication was examined and found to be in order despite the home having just changed to a new system. The Boots blisters are bulkier than the old system and new storage arrangements have had to be developed. The Boots adviser was no site on the day of Inspection to offer advice and help with a few hiccups. Boots pharmacists will oversee the homes practice and procedures on medication and will visit the home to carry out checks regularly that will generate a report and will offer advice and training if needed. Service Users voiced content that they are treated with respect and that their right to privacy is upheld. On admittance the home will ask the Service User to tell them what arrangements they have made in the event of their death and staff receive training in dealing respectfully and sensitively with death and bereavement. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 Page 10 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 standard were inspected during this visit. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Service Users and their families feel that the lifestyle in the home matches their expectations, preferences and satisfies all their needs. Contact is maintained with friends and family and Service Users are helped to exercise choice and control over their lives. Food offered is varied and wholesome. EVIDENCE: The Service Users the Inspector spoke with and those who replied to the user survey as well as the family members who were visiting on the day of the Inspection all expressed satisfaction, saying that the home addressed their needs socially, culturally and offered religious support if requested. They felt that activities that were offered were adequate. Contact with family and friends is encouraged by the home and visitors are welcome at any reasonable time of the day. Service Users talked of visits they received and 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. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 Page 11 The food served during the Inspection looked appetising and was presented in a pleasing manner. I can be eaten either in an attractive dinning room or in the Service Users room if preferred. Copies of the menus show a wide choice, there is always an alternative offered each meal and the cook visits each Service User daily to take orders for the day, if anyone has a special request the cook will endeavour to supply it. The fridge and larders were well stocked and were clean and well ordered. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 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): All standards were judged on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Service Users felt 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 residents are enrolled on the electoral role. Staff receive training in recognising and reporting abuse. 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 Service Users 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 Service Users would be given access to legal advice it 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 Service Users from abuse by making required checks and files that were examined showed that those checks have been made; CRB checks are carried out and references are taken prior to employment. Staff are offered protection of vulnerable adult and whistle blowing training. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 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 standards were judged on this occasion. Quality in this outcome area is good. This judgment had 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, Service Users have their own possessions around them. All of the 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. There are various comfortable communal areas both large and small that offer quiet areas, a TV lounge and one that has a radio and music system. There are several communal lavatories that are easily accessed and have adaptations such as riser seats and grab rails. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 Page 14 All of the bedrooms that were inspected appeared suitable to the users needs with room to manoeuvre and were attractively decorated and furnished. Some of the rooms contained small items of the Service Users own furniture and personal items. Despite the extremely hot weather on the day of the Inspection the home was well aired and not unacceptably hot. Fans were operating through out he home. The house was very clean and pleasant smelling. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 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 the above standards were assessed during this visit. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. There were sufficient well trained staff on duty during the Inspection to met the needs of the Service Users, the recruitment policy and procedure is as required. EVIDENCE: The rotas were examined and staff on duty corresponded to those detailed on the rota, 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; 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 a continuing NVQ 2 and 3 schedule. Training certificated were held on staff files. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 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): All standards in this area were assessed during this visit. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. The Registered Manager has undertake the Commissions fit person procedure and appears to be well organized and of good character, there is a high standard of record keeping, polices and procedures. EVIDENCE: The Manager facilitated the Inspection in an open and friendly manner and all staff and Service Users asked said she was supportive and caring. Staff felt that they can approach her for help and advice, the Service Users said that she will listen to what they had to say and deal with issues sympathetically and confidentially. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 Page 17 Service User surveys are done regularly and 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 Service Users 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 on 18th November 05 and points being tested weekly, there was an electrical wiring certificate dated 19th May 05. Hoists and emergency lighting were serviced in March 06 and the fridge and freezer temperatures are checked and recorded daily. Staff receive Fire and Health and Safety and training. Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 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.V294918.R01.S.doc Version 5.1 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.V294918.R01.S.doc Version 5.1 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. Extracts may not be used or reproduced without the express permission of CSCI Eversleigh DS0000006914.V294918.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!