CARE HOMES FOR OLDER PEOPLE
Eversley Nursing Home 95/96 North Denes Road Great Yarmouth Norfolk NR30 4LW Lead Inspector
Hilda Stephenson Unannounced 13 April 2005 10.30am 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 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. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Eversley Nursing Home Address 95/96 North Denes Road Great Yarmouth Norfolk NR30 4LW 01493 854086 01493 857007 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Country Retirement and Nursing Homes Limited Mrs Deborah Lee Fouche Care home 18 Category(ies) of Old Age (18) registration, with number Physical Disability (1) of places Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To accommodate one (1) service user with Physical Disabilities under 65 years of age, who is named with the Commission for regular respite care in the category Physical Disability. 2. To accommodate up to eighteen (18) Older People. 3. The total number of service users not to exceed eighteen (18). Date of last inspection 6 January 2005 Brief Description of the Service: Eversley Nursing Home is situated in the town of Great Yarmouth within reach of local shops. It is a three-storey building with access to the 16 single and 1 shared room by a shaft lift. The communal areas consist of two lounges and one connecting small dining room with a separate quiet relatives room. The home has a patio area with shrubs and flower beds and has small space for parking. Eversley is a registered care home that provides nursing care for 18 older people and is owned by Country Retirement and Nursing Homes Limited. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over three and a half hours and was carried out as an unannounced inspection during the busy morning and lunch time period. A partial tour of the premises took place, staff records, a selection of policies and care records were examined. Nine of the fifteen residents, all six of the staff on duty and two new care staff who were supernumerary were spoken to. What the service does well:
The home has a small group of staff that has worked at the home for some time, who acknowledge the residents’ needs and have developed a friendly atmosphere. There are organised activities taking place with both group and individual interests being adopted. A group activity was taking place during this visit in the front lounge with a variety of games between residents supervised by one of the care staff. The frailer residents who tend to sit in the rear lounge were listening to music with staff and some residents joining in with the popular songs. Residents are offered a variety of meals from the menu. The home has received the ‘Investors in People Award’ after a recent audit of the service for a further three years. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 6 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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 standard(s) 1, 3 & 5 Written information is given to prospective residents to explain the facilities offered at the home during the admission process. An assessment of care and nursing needs is undertaken and recorded prior to admission. EVIDENCE: The statement of purpose and service user guide contains relevant information and is available for all new residents or their relatives. The manager visits all prospective residents to ascertain that the home can meet their needs by following the assessment procedure, and can offer a place for a trial period of six weeks, when a review of the resident’s care needs are re-assessed to ensure the resident has settled within the care environment. The assessment records recorded by the manager are contained within the care plan of each resident. One resident who has lived at the home for some time stated that ‘I first met the manager while I was in hospital, she and her staff helped me settle in here, my son came to see my room because I was too poorly, I’ve got my own things around me now’.
Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 9 The three care records that were examined contained details of the six weekly review meeting. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Care Plans include nursing, social and health care needs that are reviewed by knowledgeable staff that have a good understanding of each individual resident. EVIDENCE: Care plans are in place for each resident, within the care plans that were examined, three contained evidence that residents or their relatives have given some input when they were originally compiled. One resident who was asked by staff what help she would like said ‘ the nurse asked me and I know that written records are in my folder, because instructions are in it for the new staff’. Care records are kept in individual folders with daily records providing evidence of treatment and their progress. Medication is administered by trained nurses following safe medication procedures and kept secure within a locked cupboard. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 11 The pharmacist has recently changed the collection of returned medicines so the home needs to reorganise the safe disposal of returned medicines. Observation during this visit showed staff respect resident’s privacy and treated them in a friendly but respectful manner. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 15 Social activities are arranged which take into account residents’ interests with a variety of group and individual activities. Residents are offered a variety of meals from the menu. EVIDENCE: Residents confirmed that they are offered a choice of meals from the menu. The cook confirmed that she catered for several types of specialised diets, with residents being assisted by providing them with an assortment of adapted cutlery and crockery. The menu is altered over a four-week period combining seasonal changes and includes resident’s suggestions from time to time. Staff were observed assisting residents with their lunch in a dignified and unhurried manner. The dining room is small and can become quite crowded, although several residents stated that they preferred to have their meals at their own individual tables. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 13 During this visit one member of staff was supervising a game of dominoes between two residents and then organised a game of darts, it was noted that all the residents took part. The residents in the rear lounge were listening and singing along to popular tunes with several of the staff taking part. Some residents preferred to sit quietly and one stated that ‘she is happy just to watch’. Another resident stated that ‘I go out to the pub with my relatives and occasionally to the seafront’. The home encourages relatives to continue with their visits and outings with the residents with several comments seen in the care records of the amount of outings that some residents have had. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has a clear complaints system in place with written evidence that resident’s views are taken seriously and acted upon. EVIDENCE: The home has had no complaints since the previous inspection. Any complaints and the action taken are contained within the complaints folder. The complaints policy is contained within the service user’s guide and is left in each bedroom. The manager highlights the complaints procedure to both resident’s and relatives and meets with them on a regular basis. One resident stated ‘there’s nothing to complain about here, we get everything we need’; with another resident stating ‘the staff are lovely who would complain about them’. A procedure is in place for responding to allegations of abuse. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23 & 26 In general the home is decorated when needed, with the bedrooms redecorated when they become vacant. However several areas still require attention. EVIDENCE: The home’s communal areas consist of two lounges on the ground floor with small dining room situated off the rear lounge. A small relatives room is also situated on the ground floor. A partial tour of the home was undertaken. Several bedrooms have been redecorated since the previous inspection. Two bedrooms that were seen continue to require attention although there is no risk to residents. The home was clean and reasonably tidy with no unpleasant odour. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 16 The home requires the drier to be repaired to ensure that resident’s laundry is provided. The home should continue to maintain and improve the environment to provide a safe, clean and well-maintained place to live and work. It was recommended that the extractor fan in the kitchen be repaired due to a build up of fumes during busy periods. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Sufficient numbers of staff are on duty to meet resident’s needs with extra staff brought in to cover busy periods. EVIDENCE: There is usually one trained nurse and three care staff during the morning when the home is fully occupied reducing to two care staff and one trained nurse when there are empty rooms. The manager tends to work from Monday to Friday although covers at weekends occasionally when a member of staff is off. A cook and domestic are also on duty during the day. The home currently has eleven care staff and four nurses although a new nurse will be commencing after the relevant recruitment procedure has been completed. The home encourages the care staff to undergo the recommended NVQ training with two thirds having obtained this, several have commenced the more in depth NVQ level 3 training in care to develop their care skills which should be commended. The training records that were seen were satisfactory. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 36 & 38 The management of the home is satisfactory although more support from the proprietors would reduce the amount of ongoing improvements. EVIDENCE: The manager supervises the staff with written records seen to show this has been undertaken. The supervision sessions enable the manager and staff to discuss their training needs and staff who spoke to the Inspector confirmed that they feel very well supported by the manager. There is a quality assurance system in place where residents and relative views have been received with the action for improvements that have taken place during past year. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 19 The home has a fire procedure to follow with records in place to confirm this. The home still requires a fire risk assessment. The accident procedure was seen and complies with the accident reduction procedure; the manager audits the amount and risk of accidents. The manager should compile a maintenance plan to allow the proprietor to plan the improvements. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 2 3 3 x 2 x x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x 3 x 2 Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 21 Yes 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. 1. 2. 3. 4. 5. 6. Standard 23 23 23 26 38 19 Regulation 23 23 23 16 23 23 Requirement The ceiling in bedroom 3 needs attention. The flooring in bedroom 4 needs replacing. The bedside light in bedroom 4 needs repairing. The drier in the laundry must be in good working order to meet residents laundry needs. The home must have a fire risk assessment for the environment in place. (This is outstanding) The manager should compile a maintenance plan for the proprietor to arrange for improvements. Timescale for action 30/6/05 30/6/05 30/6/05 Immediate and ongoing Immediate and ongoing Immediate and ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 19 Good Practice Recommendations The extractor fan should be in good working order in the kitchen to reduce the risk of contamination and inhalation of fumes. Eversley Nursing Home I55 S15636 Eversley V221440 130405 Stage 4.doc Version 1.20 Page 22 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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