Inspection on 22/02/08 for Eversley Rest Home

This inspection was carried out on 22nd February 2008.

CSCI found this care home to be providing an Adequate service.

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

Eversley Rest Home 12/01/09

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Eversley Rest Home 38 Bramshall Road Uttoxeter Staffordshire ST14 7PG Lead Inspector Jane Capron Key Unannounced Inspection 22nd February 2008 10:00 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 Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eversley Rest Home Address 38 Bramshall Road Uttoxeter Staffordshire ST14 7PG 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) 01889 563 681 Mrs Johanna Barrett Miss Anna Marie Kirkland Care Home 22 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (22) of places Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 22 Dementia over 55 years of age (DE) 3 The maximum number of service users to be accommodated is 22 2. Date of last inspection First inspection Brief Description of the Service: Eversley is a care home for 22 older people. It is owned by Mrs J Barrett who bought the service in May 2007. The service is located in a large Victorian property that has been extended at the side and rear. It is a short drive from the centre of Uttoxeter. The property is set back from the road behind tree and bushes. There is large car park at the front. There are grassed areas at the rear. The accommodation offers two large lounges and a separate dining room. The service provides all single bedroom accommodation with 11 rooms have ensuite facilities. They service has a vertical lift and a stair lift. The fees are not identified in the service user guide and therefore anyone who may want to move to the service should contact the service direct. The additional costs include toiletries, the installation of a personal telephone if wanted and hairdressing. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place over one day and lasted approximately six hours. We looked at a range of records relating to Health and Safety, the care people receive and the way the service employs staff. During the day we spoke to the manager, a number of staff and people that live at the service. We also spoke to a relative and a District Nurse that were visiting the service. We looked at how the service is meeting people’s health and personal care needs and whether the service is providing people with things to do during the day. We also looked at the meals provided and how the service keeps people safe. A sample of accommodation was looked at including some bedrooms, bathrooms and the communal rooms. Prior to this inspection we looked at information we had received during and after the service was registered. What the service does well: People enjoy living at the service and are pleased with the care they receive. Comments we received include: ‘ The staff are caring’, ‘I like it here’. ‘Can’t grumble about anything’ and ‘I like it here very much’. People told us they would recommend the service to other people. The service meets the personal care and health care needs of people living there in a way that respects their privacy and promotes their dignity. People like the meals provided and there is a choice at all meals. The service is able to provide meals for people on some special diets. The staff are motivated and work to provide care in a way that people want. A health care professional says that the staff are ‘very competent’ and follow up any advice given to them about people’s health. A relative also says that they feel the staff are ‘conscientious’. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 6 Overall the service provides good accommodation. All bedrooms are single and a number have ensuite facilities. People can lock their bedroom and can bring in pieces of their own furniture. The service has attractively decorated and furnished communal areas. The way the service recruits staff makes sure that they have the necessary checks. The service has a high number of trained staff and provides staff with ongoing training in areas such as dementia care and specific health care needs. What has improved since the last inspection? What they could do better: Whilst the service is providing some good outcomes for people there are areas that need to be improved. Currently the service does not have a Statement of Purpose that gives information about the service and what it offers. Improvements are needed in some areas of the care plans to make sure that all the information is present to support staff to meet people’s needs. The service also needs to have procedures in place to make sure that bedrails are safely maintained. There are areas of medication practices that need to be improved to make sure that no errors in medication will occur. All staff need to have regular fire drills to make sure they can respond correctly in the vent of a fire. Please contact the provider for advice of actions taken in response to this Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 8 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 Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The way the service admits people makes sure that their needs are assessed and they are able to visit the service. However the service does need to ensure that sufficient information is available for people to be fully clear about what the service offers. EVIDENCE: Currently the service has no Statement of Purpose available and the manager said that the owner is in the process of updating this following taking over the service in May 2007. There must be a Statement of Purpose in place that outlines that aims and objectives and the faculties and services provided to people that live at the service. There is a service user guide in place that is provided to people living at the service and people who may be interested in moving there. This could be Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 10 further expanded to included greater detail about the service and could be provided in a more east read format. The service user guide is given to people with the complaints procedure and a sample of a contract. The guide did not provide people with information about the availability of the last inspection report although the last report is displayed in the entrance hall. Files we looked at show that people have a contract in place and this outlines their rights and includes the number of the room they are to occupy. Our examination of a sample of files show that assessments of people’s needs are undertaken before they a place is offered to them. The assessment information about people’s health and personal care needs and also about their social care needs including their interests, spiritual needs and family relationships. People told us that they can come and look round before deciding to move to the service although in many cases relatives visit on their behalf. One person told us that her relatives can to look round as she was in hospital and another person said they had been to look round themselves and felt that when they visited the service was ‘homely and friendly’. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People are having their health and personal care needs and are treated with dignity and respect but the service needs to make sure that information about people’s needs is comprehensive and that people are fully involved in planning their care. People’s medication needs are generally met although the service needs to make sure that proper procedures are in place and are always adhered in order that the likelihood of errors is reduced and people are fully protected. EVIDENCE: Our sampling of records show that people have care plans in place that outline their needs. These include health and personal care, mobility and social care needs as well as other areas specific to individual people living at the service. Plans need to include mental health needs where this support is needed. The plans also need to demonstrate that people or if appropriate their relatives are involved in their development. Talking to staff show that they are aware of Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 12 each person’s needs and know how they like their care to be provided however this information was not always included in the care plans. The service is meeting people’s health and personal care needs. Records show that people receive health care services when they need it. A health care professional visiting the service feels that the service refers issues including tissue viability issues appropriately and that staff always follow any health advice they are given. We would recommend that the service keep records of people’s regular tissue viability assessments and reviews. The service monitors people’s weight through monthly weighing. Several people are using bedrails and in all cases except one an assessment is in place. However in this case there was an assessment in place completed by the health care professional. There is no recorded system in place to regularly check that the bedrails continue to be fitted correctly. People living at the service say they receive good care from the staff that respect their privacy and care for them in the way they want. They tell us that they see the doctor when they are ill and that the optician and chiropodist visit them. Observation during the inspection show that the staff treat people with respect and explain any care they are going to provide. We saw that staff are aware of people’s dignity for example making sure that people are properly covered when their legs are raised in reclining chairs and making sure that people are appropriately dressed in clean clothes and have clean hair and nails. There are positive, relaxed and friendly relationships between staff and people living at the service. People receive health care treatment in the privacy of their own bedroom. As part of the inspection we looked at how the service is supporting people with their medication. Staff are trained in medication administration. No-one at the service is managing their own medication. The service is using a monitored dosage system for the administration of medication. The manager identified that she is aware that there are issues over some medication practices and is working with staff to address these. The service is recording medication that is received but needs a system in place in order that proper auditing medication can take place. The service is recording medication that is returned to the pharmacist. The service is generally making sure that people receive the correct medication but the service needs to look at its arrangements for administering medication at times other than on the regular medication rounds. In respect of this medication there are some gaps in the Medication Administration Records and the service’s systems could not show whether the medication has been administered and not signed for, or not administered. The service also needs to make sure that where medication is labelled ‘ as required’ protocols are in Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 13 place so that all staff are aware of the circumstances when it should be administered. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service promotes people’s rights to make choices and decisions about their lifestyle. People have the chance to take part in activities and to have their spiritual needs met. People have meals that provide them with variety and choice. EVIDENCE: Discussions with people that live at the service show us that people are supported to make choices about their life and to live the lifestyle they wish. The service consults people both individually and through service user meetings seeking their views about for example meals and activities. People choose where to spend their time, in the lounges or in their bedroom. All bedrooms provide people with privacy being lockable. Meals can be taken in people’s rooms if they wish. People get up and go to bed when they wish. Two people said they watch the football in the evening going to bed afterwards and another person told us they liked to go to their room early in the evening and watch TV and read in their bedroom. Breakfast is served early for those Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 15 that get up early. People make choices about whether they take part in social activities. People are able to make their bedrooms their own brining in a range of possessions including items of furniture. One person also said she sits in the lounge in an armchair she had brought in with her. The service provides a number of activities for the people living at the service and they are plans to further develop this part of the service. A staff member has recently completed a training course aimed at developing and promoting people’s social care needs. Current activities include gently exercise, craft making, bingo, singing and the opportunity to watch videos and DVDs. There are also entertainers coming to the home occasionally such as a musician and an indoor gardener. Occasional trips out of the service take place but the availability of transport restricts this. Special occasions are marked for example last Christmas the service had entertainment including carol signing and hand bell ringers. People’s birthdays are celebrated with a birthday cake and drinks. People’s spiritual needs are considered. A Church of England service is held once a month and a representative of the Roman Catholic faith visits members of their congregation regularly. The service encourages relatives and friends to visit the service and there are no restrictions on when they can visit. Some people we spoke to said their relatives visited them daily. People speak very highly about the meals. Comments include: ‘food- lovely’, ‘there is always a choice’, ‘always fruit and veg. available’ and ‘ you won’t loose weight if you live here- the food is so good’. The home is providing people with a varied menu that provides people with choice of all meals. The breakfast menu is porridge, cereals and toast although if people wish they can have something on toast. The main meal is served at lunchtime and on the day we visited it was fish, chips and peas or Cornish pasty, chips or mashed potato and peas followed by two types of crumble and trifle. An example of the tea menu is soup, choice of sandwiches or fishcakes, followed by homemade cakes and buns. Ice cream, fruit and yoghurts are available at all meals. Supper and snacks and drinks between meals are provided. If someone specifically wants something this can be provided. The service provides a diabetic menu. We observed lunch being taken and meals are provided individually rather than being plated up. People are asked what they want and how much. People are offered a second helping. We also saw that the service provides people with adapted cutlery and lipped plates where needed to support people to eat independently. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People that live at the service are consulted about their views and there are procedures in place to deal with concerns. The staff’s training and the service’s procedures help people to feel safe and to be protected. EVIDENCE: The service has a complaints procedure that is given to everyone living at the service and their relatives. This could be provided in amore easy read format. The service keeps records of any complaints and the provider had dealt with the one it had received. The matter was investigated and the outcome provided to the complainant as required. The service seeks people’s views through individual and home meetings. We feel that there is an ‘open culture’ at the service where people will feel able to raise concerns. There are relaxed friendly relationships between staff and people that live at the service. The Care Manager has a high presence in the home and has regular contact with the people living there. There are procedures in place to safeguard people. Staff are appropriately recruited making sure that the necessary pre employment checks are made. Staff are provided with information about adult protection as part of their induction and as part of the training for those staff that have an NVQ. Plans are in place to provide all staff with further safeguarding training. People told that they feel safe at the service and feel that the staff are very caring. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 17 Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with communal and private accommodation that is clean and adequately maintained and decorated. The amount of bathing facilities for people is limited and people would benefit from the provision of a bath downstairs. People benefit from accommodation that is clean and hygienic. EVIDENCE: The premises are suitable for the people living there. The manager tells us that the owner has a plan to improve the service. People that live at the service have suitable communal rooms –2 lounges and a separate dining room. The lounges provide comfortable areas with a range of seating and TV and video/DVD facilities. These areas are well decorated and are warm and provide suitable lighting including natural light from large windows. Lounges Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 19 have pictures on the walls and flowers around the room. The separate dining room provides enough seating for everyone to eat together. Tables have clothes and serviettes and flowers on each table. The room provides a pleasant place to eat. Certain areas of woodwork particularly the doorframes and skirting boards in the communal areas did need to be painted. People have limited bathing facilities. Downstairs there is a shower room that is also used as the hairdressing salon. We did see that this area was quite cluttered and was being used for storage. The manager said that they are thinking of putting a bath in this room as currently there is only one useable bath and this is upstairs. There are adequate numbers of toilets. Everyone at the service has a single room and several people told us that they like their bedroom. 11 bedrooms have ensuite facilities. The bedrooms looked at are suitable to meet people’s needs. They are all lockable, radiators are covered and people have a drawer that locks where they can keep things securely. Bedrooms have adequate furniture although some is quite worn. All rooms have seating. Lighting is sufficient and everyone can have a bedside light. People personalise their rooms bringing in pieces of their own furniture and a range of items such as photographs, pictures and small ornaments. Rooms have TVs. The service had a large kitchen with food storage room off. This was suitable to cook people’s meals. A new cooker has recently been installed and therefore a lot of non-food items are being stored in the food storage area. This room needs to be cleared and only used for food storage. The home is clean throughout and a health care professional said she had never had any concerns of hygiene issues. The service employs a domestic and has cleaning schedules to make sure that the service is kept clean. There are suitable laundry facilities. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and are available in adequate numbers to provide people with the support they need. The service’s recruitment procedures are safeguarding people that live at the service. EVIDENCE: The staffing levels at the service are currently adequate due to the dependency levels of the people currently living at the service but this needs to be kept under review. The service has 3 care staff on duty until early afternoon and this then reduces to 2 for the afternoon and evening. During the day the manager is available for support and from 4:30 pm a young person provides additional non-care support such as helping serve tea and drinks and talking with people. People living at the service are full of praise for the current staff and several people told us that the staff are ‘very caring’. Other comments include one from a relative saying they feel they staff are ‘conscientious’ and a health care professional stating they feel the staff are ‘very competent’. There is a friendly atmosphere where staff and people living there have relaxed and positive relationships. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 21 Staff members have a caring attitude and good values. There is a good core of staff that have worked at the service for some years. One staff told us that the way she works is to ‘treat people as you would want your relative to be treated’ and to ‘ provide choice to people’. Staff told us that they receive training in care practices and have received recent training in dementia care, stoma care and peg feeding. There is a good percentage of the care staff, 8 out of 13, trained to at least NVQ level 2 and a further 2 staff are due to start the training. New staff undertake induction training covering care practices and the necessary Health and Safety training, Sampling of files confirms that the service completes pre employment checks on staff. All have Criminal Record Bureau and Protection of Vulnerable Adult checks as well as 2 references. People’s identify is confirmed although a new member of staff still needs to have a photo on their file. Confirmed that all staff including night staff trained in fire, medication, moving and handling, food safety and a number have had infection control training. Saw evidence that update for moving and handling planned for March 2008. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced to lead the service in the interests of the people that live there. The systems for reviewing and developing the service could be improved to ensure that there is continuous process of improvement for people that live there. The service health and safety practices are generally safeguarding people although there need to be regular fire drills taking place. EVIDENCE: The Manager of the service is very experienced and has managed the service for several years. She is suitably trained and qualified to manage the service. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 23 She undertakes training to remain in touch with current practice having recently completed training in dementia care, palliative and stoma care and peg feeding. The service has some systems in place to monitor and review the service. The manager checks environmental issues and has meetings to seek the views of people that live at the service and staff. She is also readily available in the service and has regular contact with people that live there. We would recommend that further audits including about care issues are completed and that the service seeks the views of relatives and health and social care professionals. This would provide more information to identify areas where the service could be further developed. The service is not the appointee for anyone living there but does look after small amounts of money for people. Checking of records shows that they service maintains a running record of income and expenditure and that receipts of any expenditure is kept. People’s money is kept separately and securely. The service has Health and Safety procedures in place and provides staff with the necessary training in moving and handling, fire and food safety. The Environmental Health department had visited recently and had awarded the service 4 stars. They had identified some recommendations that the service was following up. The service is checking the fire alarm, emergency lighting and fire equipment. The fire drill had taken place but this occurred some time ago. We were informed that due to problems with the fire alarm panel there were difficulties in having fire drills. The service had a fire risk assessment and the manager was in the process of updating this. As part of this she was looking at the individual arrangements in place for each person to evacuate the premises. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 24 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 1 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X 3 3 3 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 3 X 2 X 3 X X 2 Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The service must have a Statement of Purpose in place. This will make sure that people have all relevant information available to them in order to know what they can expect from the service. Where people have mental health needs these must be included in the care plan. This will make sure that people’s needs are fully identified. Where bedrails are fitted an assessment must be in place and regular checks must take place to ensure they are fitted correctly. This will ensure that people are protected. Accurate, complete and up to date records must be kept of all medication received administered and disposed of to ensure that medication is accounted for and is given as prescribed. Medication must be administered as prescribed. This will make sure that people receive their medication at the time they need DS0000069912.V359909.R01.S.doc Timescale for action 01/04/08 2. OP7 15 01/04/08 3. OP8 12(c) 22/03/08 4. OP9 13(2) 22/03/08 5. OP9 13(2) 22/03/08 Eversley Rest Home Version 5.2 Page 26 6. OP9 13(2) 7. OP36 24(4)(d) it. Where medication is labelled ‘as required’ protocols must be in place. This will make sure that information is available so that such medication is administered consistently. To ensure that the fire alarm panel is in working order thereby allowing fire drills to be held. This will make sure that all staff are aware of how to support people in the event of fire. 01/04/08 17/03/08 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. 2. Refer to Standard OP1 OP7 Good Practice Recommendations To further develop the service user guide and to provide this in a more accessible format. This will provide people with full information about the service. Care plans to be further developed and to evidence that people views are included in their development. This will make sure that people are provided with care in the way they want. The service to record their assessments and regular reviews of people who are at risk of developing pressure sores. This will make sure that people’s needs are kept under regular review. To develop further opportunities to people to take a part in activities including accessing the community. This will provide people with a more varied and fuller lifestyle To provide a bath downstairs. This will make sure that people whose bedrooms are downstairs do not have to go upstairs for a bath. To make sure that the shower room downstairs is not used for storage. This will mean that people can use the shower. For the scuffed paintwork in the communal areas to be repainted. This will improve the accommodation for people living at the service. DS0000069912.V359909.R01.S.doc Version 5.2 Page 27 3. OP8 4. 5. 6. 7. OP12 OP21 OP21 OP19 Eversley Rest Home 8. OP33 To develop the system for monitoring and reviewing the service. This will make sure that there is sufficient information to evaluate the service and to develop a plan to improve the service. Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Eversley Rest Home DS0000069912.V359909.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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