Inspection on 13/06/05 for The Evergreens

This inspection was carried out on 13th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Evergreens 25/01/07

The Evergreens 31/01/06

The Evergreens 05/01/05

The Evergreens 27/08/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Evergreens Hemlington Village Road Middlesbrough TS8 9DE Lead Inspector Val Daly Unannounced 13 June 2005 09:30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Evergreens Address Hemlington Village Road Middlesbrough TS8 9DE 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) 01642 599744 Salco Homes Limited Mr Anthony Griffiths Care Home 18 Category(ies) of LD Learning disability (18) registration, with number PD Physical disability (15) of places The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10 February 2005 Brief Description of the Service: The Evergreens is registered with the Commission for Social Care Inspection under the Care Standards Act 2000 as a care home to provide care and accommodation for eighteen adults who have a learning disability. The home is compromised of three single storey dwellings, Juniper having nine places, Redwood having three places and Aspen having six places. The care home is situated in a secluded site set back from a main link road and close to a popular public house and has views over undeveloped grassland. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 9.30am and lasted for four hours. Numerous records including care assessments and care plans were examined. A tour of the three bungalows was carried out. What the service does well: What has improved since the last inspection? What they could do better: Documentation for the assessment of residents should be clearer. Whilst staff are aware of the needs and wishes of the residents, the care documentation needs to be developed further to show this and how they are being met. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2 Information about the home is available for residents. Assessments for residents are unclear. EVIDENCE: The home has a Statement of Purpose in place, which gives detailed information about the service, accommodation and local amenities. Whilst the residents have lived in residential care for some considerable time, there was no clear assessment to identify their needs and abilities to enjoy day to day life. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 7 The individuality of residents is constantly promoted and they are encouraged to make choices about their lives but this needs to be recorded more fully. EVIDENCE: Care records showed that residents are included in the care plan process. However the system is disjointed and unclear. Care plans were not evaluated to show improvement or deterioration in the residents needs. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 14 Residents are assisted to lead active and fulfilling lifestyles by having a regular community presence and by accessing a range of community facilities. EVIDENCE: The majority of the residents spend time in day centres and educational facilities. At weekends and evenings residents are involved in a variety of activities of their choice such as shopping, bowling, cinema, local pubs, leisure centres. There are also activities available in the home and garden, football, cricket and a snooker table for the residents. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Residents are not protected by the system for the administration of medication. EVIDENCE: The home has policies and procedures for the administration, receiving, storage and disposal of medication. However on one administration record tippex had been used to change a signature. Also for one resident medication had been omitted without a reason being documented. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These two standards were not assessed at this inspection. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The home is comfortable, however some areas require refurbishment. EVIDENCE: In Aspen unit the wallpaper in the lounge requires re pasting in some areas. The carpet and suite are well worn. Bedrooms are personalised, individual and clean and tidy throughout. In Juniper unit an area in the corridor carpet is a tripping hazard. There is a large damp patch on the wall in the corridor outside the shower room, which requires repair. The bathrooms were damp with mildew, tiles need re grouting and the shower heads also require cleaning. Testing for legionella is required. In Redwood unit the tiles in the bathroom require re grouting. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 36 Residents are supported and protected by the home’s recruitment processes. The Staff supervision system needs further development. EVIDENCE: The home has a recruitment policy and procedure in place. Four staff files were examined and they contained the required information showing that procedures were being followed. The manager said he has commenced supervision with senior staff and carers. Senior staff have been given training to carry out supervision for carers. This needs to be formalised. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Health and safety policies are in place, which help staff and the manager run the home efficiently and for the benefit of the residents. EVIDENCE: The manager is appropriately qualified and experienced to ensure that the health, safety and welfare of residents and staff is always promoted and protected. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score x x x 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Evergreens Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 17 No 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. Standard 20 24 30 Regulation 13 23 23 Requirement Medication administration records must be fully completed. Tippex must not be used. Re furbishment is required in some areas, particularly in bathrooms and communal areas. Shower heads in the bathrooms require cleaning Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 2 6 36 Good Practice Recommendations Documentation for assessing residents needs and abilities to enjoy day to day life needs to be clearer. Care plans ned to be evaluated. A formal staff supervision system needs to be in place. The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale Stockton on Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Evergreens v232474 b51-b01-s55 the evergreens v232474 130605 stage 4.doc Version 1.30 Page 19 - 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. 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