Inspection on 06/04/09 for Eversleigh

This inspection was carried out on 6th April 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eversleigh 13/04/07

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 12/10/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Eversleigh 13 Sundridge Avenue Bromley Kent BR1 2PU     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Rosemary Blenkinsopp     Date: 0 6 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Eversleigh 13 Sundridge Avenue Bromley Kent BR1 2PU 02084642998 02084642998 eversleigh@cnvltd.wanadoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : C.N.V. Limited care home 31 Number of places (if applicable): Under 65 Over 65 31 old age, not falling within any other category Additional conditions: 0 The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP The maximum number of service users who may be accommodated is: 31 Date of last inspection Brief description of the care home 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 wellmaintained gardens, with some off-road parking to the front. Residents 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. Care Homes for Older People Page 4 of 27 Brief description of the care home 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. The newly developed top floor is very pleasant. Work is underway to the exterior parts of the building including the roof. Despite all the work that is in progress the residents are not being unduly inconvenienced. The fees range between £560- £1000 per week. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The inspection was a key inspection conducted over a one day period. The manager facilitated the site visit. Also in attendance for part of the day was the new Regional Manager for the group. Prior to the inspection the manager had not completed the AQAA, although the previous one was produced during the inspection, and it was said that there had been few changes to that information already provided. Six comment cards were received including two from staff and four from residents. During the site visit the inspector met with one relative, several residents and the visiting GP. Staff were interviewed as part of the site visit. Care Homes for Older People Page 6 of 27 All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans staff personnel files as well as health and safety records. Feedback was provided to the manager at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 27 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All prospective residents are appropriately assessed prior to admission; and further information received from members of the multi disciplinary team, provides staff with a good knowledge of the residents care needs from which they can deliver care. Evidence: Assessments confirmed that relatives and healthcare professionals had been involved in the pre admission assessment. Residents spoken to during the inspection said that they had been asked for their views on care needs and their expectations of the service to be provided by the home. Staff spoken to said that the information contained within the assessment helped them to formulate care plans and risk assessments individual to the health, personal and social care needs of the person. Staff also said that the information provided gave them an insight into the persons needs enabling them to care for the person. Care Homes for Older People Page 10 of 27 Evidence: A Statement of Purpose and a Residents Guide is given to all new residents when they move in, and a copy is also displayed on the table in the entrance hall. Care Homes for Older People Page 11 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans seen reflected the assessed health, personal and social care needs of the individual and gave clear guidance on how these needs were to be met. All healthcare needs can be met by staff in the home supported by the multi disciplinary team. The people who use the service feel confident that they will be treated with respect ensuring that their privacy and dignity is maintained at all times The medication policies, procedures and practice ensure that the people who use the service are given the correct medication at the correct time by competently trained staff. Evidence: Each resident has an individual plan of care. The information is retained in two separate files which provide comprehensive information on the resident and thier needs. The care plans were personalised to the individual resident and identified their specific personal, health and social care needs. They provided information on specific Care Homes for Older People Page 12 of 27 Evidence: ways in which these needs were to be met respecting the independence, privacy and dignity of the individual being cared for in the home. The care plans also included risk assessments relating to moving and handling, nutrition, falls and mobility, behaviour problems, and skin integrity. These had been subject to regular reviews. All care plans seen were signed by the resident and staff member and had a monthly review recorded. The home has some equipment in use for instance bath mobility hoist, walking aids and pressure relieving beds. Currrently there are no residents who require hoists to be used as they are fairly mobile and the home does not have a hoist on site. The manager advised that she had tried some hoists, but width restictions into the lift and under some furniture had deemed it not suitable. There was a long discussion about the use of hoists and the home needs to have all equipment available to meet residents needs - as this may change at any time. In addition staff have to be able to use hoists safely and need to practice on equipment . This must be addressed. The G.P. attended towards the end of the morning and spoke to us. He was very pleased with the service provided, felt staff were proffesional, receptive and followed instructions. They sought assistance quickly and overall the home provided good health care. Comment cards from residents included the following statements very attentive and considerate care, friendly and curteous staff . The senior care staff was doing the medications as we arrived. She confirmed that she had recieved medication training some time ago. Staff who administer medications need to have regular training to ensure they are competent to undertake medication procedures The practice was safe. Afterwards the records were checked for accuracy. There was a list of staff signatures of those who admisinster medications. On several of the medication charts the allergies section was not completed. On disscusion with the staff she said only those residents who had known alleregies would have them documented. All charts must be completed and include a statement if there are no known allergies. Those residents who required creams to be administered had their charts ticked to indicate this . Medication records confirmed medications received and destroyed were checked. The medication administration charts were completed without gaps and included residents photographs and any allergies that they may suffer. Care Homes for Older People Page 13 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home endeavours to provide appropriate activities to the residents supporting and encouraging them to maintain their chosen lifestyle in their home environment. Residents have choices incorporated into their day. Evidence: Activities were on going throughout the morning. A very enthusiastic activities co ordinator was organising these. There were several activities taking place at once which provided residents with opportunities to engage in the activities they wanted to. One resident was reading the paper. Others were doing an art class- Easter related, olde tyme music was playing and the newspapers available. There was a good feeling in the room and residents were engaging with one another and participating in one of the activities. Signs of well being were in abundance amongst residents. The home offers a variety of activities those which require active participation and others such as videos. Residents choose what activities if any, they want to participate in. The home supplies a selection of newspapers and magazines which on the site visits residents were reading. Care Homes for Older People Page 14 of 27 Evidence: The activities co ordinator had worked in the home for several years initially as the cook then a care worker, although this position was what she most enjoyed doing. In the sun room, where the activities take place, items made by residents were on dispaly Easter bonnets etc. Visiting is open an encouraged to maximise family contact. The lunch time meal was observed , there was no rush either in getting residents to the dining area or over the meal itself, which took about one and a half hours. Residents can chose where they want to eat, either in the attractive dining room or in their own room as preferred. The menu showed 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. Residents made the following comments an excellent range of food. The lunch looked and smelt appetizing and ther was little waste. Choices were offered in both food and either hot or cold drinks. Home baked cake is often on the menu which residents really enjoy. Care Homes for Older People Page 15 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service are able to feel safe and protected in the home. This is evidenced by way of the homes policies and procedures, and that staff are competent in dealing with complaints and protection issues. Evidence: The home has complaints information available and throughout a number of documents. Information was available to residents and relatives on how to raise concerns or make a complaint, in several documents, including the Statement of Purpose. Residents who spoke to the inspector cited the manager or staff member as the first port of call for referring concerns/complaints. They said that they had no hesitation in referring matters on. Staff interviews included questions in relation to adult protection and whistle blowing. Staff demonstrated a good grasp of these subjects and were aware of how to report and record such matters. They included internal reporting systems as well as Social Services departments to refer allegations on to. Staff confirmed that they received training in adult protection and whistle blowing. They felt that the open ethos of the home encourages concerns to be raised freely. Care Homes for Older People Page 16 of 27 Evidence: There have been two anonymous complaints forwarded to the CSCI in the last six months. These identified issues relating to manual handling, which is referred to in the health care section, and concerns regarding registration of the top floor extension. These were referred to the home for a response. There have been no other complaints concerns or adult protection related to the CSCI. In addition the open ethos of the home encourages concerns to be raised openly. Care Homes for Older People Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The accommodation is to a good standard and meets the needs of the people who live there. The people who use the service live in a home that is clean, pleasant, hygienic, safe and well maintained, with access to safe and comfortable indoor and outdoor communal facilities. Evidence: The home is in a residential area set back from the road in pleasant, well maintained gardens. There is scaffolding to the exterior of the building as roof work and windows are being addressed. On entering the home it was clean and pleasant smelling. All of the communal areas are tastefully decorated and there are abundant pictures, flower arrangements, and ornaments around the building, many of these had been made by resident in the art and craft sessions. There were 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 another one that has a radio and music system for easy listening. Care Homes for Older People Page 18 of 27 Evidence: The house was very clean and pleasant smelling throughout the whole of the site visit . No odours were detected in any area. There are several communal lavatories that are easily accessed and have adaptations such as riser seats and grab rails. Baths have manual hoist attached to assist those residents with mobility problems. The newly registered top floor was very nicely presented. Bedrooms were spacious well furnished and pleasantly decorated. It was of concern however that the main dining table and some side tables in bedrooms were glass. This is of concern as should a resident fall against this they may sustain serious injuries. One resident who spoke to the inspector pointed to an injury which had been as a result of a fall, although this had not involved any item of furniture. Even if residents are not prone to falls accidents can happen and the suitability of the glass furniture need to be re assessed. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home ensures that there are sufficient numbers of competent staff to meet the personal, health and social care needs of the residents in their care. This outcome is achieved by implementing thorough recruitment and selection procedures, supported by ongoing training, supervision and appraisal systems. Evidence: The home employs care staff, a number of ancillary workers to ensure the home is working effectively. The staff compliment includes senior care staff and has a number of management tiers in place to provide staff with support. Staff were observed to demonstrate patience during care procedures and engaging with residents whilst doing so. There was evidence of good team working and good staff morale prevailed. Staff seemed confident in what they were doing. Staff files were selected including those staff with whom we had spoken to. The personnel files were well organised and information easy to access. They contained evidence to show that robust recruitment procedures were in place including identity checks, references, CRB clearance and completion of the application form. Self declarations are completed in relation to medical information. Staff are issued with job Care Homes for Older People Page 20 of 27 Evidence: descriptions, an employment contract and terms and conditions of service. Night staff are only permitted to work two nights a week. This is the decision of the manager. Her reasons are that night staff can become tired easily as the night shift is a long one. In addition it is easier when staff take annual leave to cover two nights. Staff stated within comment cards received, that a high standard of care was provided, other comments were that residents were treated as individuals and equally. Staff had a good knowledge of the residents in the home. There is not a key working system in the home except an allocated person to replenish personal items. The manager felt that key working could sometimes lead to staff only caring for those in their group and a reluctance to work with other residents. The staff confirmed induction and on going training which equipped them with the skills they need to do the job. Topics which were discussed such as infection control and dealing with MRSA, were also well understood by staff we spoke to. Twelve staff have NVQ level 2, and 6 have NVQ level 3. Staff felt they were supported in their role and that the management was supportive and approachable. Care Homes for Older People Page 21 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents, relatives and advocates benefit from having a qualified, competent, accountable, and committed manager, and management structure in place. The home has quality assurance systems in place to ensure that the residents are enabled to provide input into the service. The home has systems in place to ensure the health and safety of the residents, relatives and staff are met. Evidence: During the site visit the manager and the new Regional Manager were on site. This manager was doing part of her induction with Mrs Offin and had spent several weeks with her because of her vast experience and knowledge. The manager for this facility has been in post for a number of years. The manager, Mrs Offin, facilitated the site Care Homes for Older People Page 22 of 27 Evidence: visit in an open and friendly manner. Staff and residents felt she was supportive and caring. Staff felt that they can approach her for help and advice. The inspector sampled a number of maintenance and service certificates to evidence that the building and the equipment within it were safe and suitable to use, all those seen were satisfactory. The records relating to weekly fire alarm testing had a gap of approximately three weeks in February 2009, although all other records were in place. Weekly fire alarm checks must be undertaken. Staff confirmed that supervision is provided with records kept, and that the sessions take place at regular intervals. Residents felt that they could raise issues easily with any staff member or Mrs Offin. Those residents spoken to were well able to communicate their concerns. Records showed that staff meetings take place, the last one being January 2009, where the anonymous complaint was discussed. Prior to this, it had been some time previous namely April 2008, when a staff meeting had been held. Mrs Offin said that staff had easy access to seeing her at anytime and she could be contacted out of hours. The residents meeting minutes showed that there was also a long gap since the last one and in between the meetings. Mrs Offin provided the same response. Both staff and residents confirmed that Mrs Offin was available and had an open door policy. A residents/relatives survey had been conducted January 2008 and the results with a short report were available. Regulation 26 visit reports were available although not all were monthly. The content of the reports was to a good standard. Residents money was safely stored and those finances selected for checking were found to be correct. Receipts were in place for expenditure and a balance sheet evidenced all transactions. Care Homes for Older People Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 18 Staff must have training and 20/09/2009 be regulaly updated in medication procedures. Staff who give out medicines need to be trained and competent in this area. 2 9 13 All information must be recorded in respect of medication particulaly allergies. To ensure residents have medication safely administered to them. 20/05/2009 3 25 23 The glass topped tables must be risk assessed and their suitability in this type of home reviewed. All areas of the home must be safe for residents to live in and free from potential harm . 30/04/2009 Recommendations These recommendations are taken from the best practice described in the National Care Homes for Older People Page 25 of 27 Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!