Inspection on 25/01/07 for The Evergreens

This inspection was carried out on 25th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Evergreens 31/01/06

The Evergreens 13/06/05

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 Key Unannounced Inspection 25th January 2007 09:30 The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 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 The Evergreens DS0000000055.V328718.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 Adults 18-65. 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. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Evergreens Address Hemlington Village Road Middlesbrough TS8 9DE 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) 01642 599744 F/P 01642 595744 Salco Homes Limited Mr Anthony Griffiths Care Home 18 Category(ies) of Learning disability (18), Physical disability (15) registration, with number of places The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 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 DS0000000055.V328718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was completed by one inspector over two days. As a key inspection, all of the key standards were examined. A tour of the home took place, resident’s records were examined, records including accidents, complaints and menus were looked at and a number of residents, a member of staff, the manager and the area manager were engaged in discussion about life at Evergreens. Since the previous inspection the home is under new ownership. What the service does well: What has improved since the last inspection? The organising and availability of training for staff has improved and many staff were in the process of enrolling for NVQ level 2. The garden in the courtyard area and the paved area around the home were well maintained and tidy. Re decoration in all the bungalows is on going and residents and relatives choose colours in their rooms. A quality assurance audit had been carried out, involving residents, relatives and staff. From the outcome of the audit the manager had put an action plan in place. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident’s care needs are assessed prior to the move to the home, and periodically thereafter. This will help ensure that each resident’s needs are met at the home and inappropriate admissions avoided. EVIDENCE: Two residents files were examined and they both contained a full detailed assessment of needs. It gives information on what the resident can do, what they would like to do and what they need help with. There is also a ‘pen picture’ of the resident giving their likes and dislikes, with the information being gathered from the young person and their relatives. The assessment looks at twenty aspects of daily life; self advocacy, eating/drinking, personal hygiene, continence, dressing, sleeping, mobility, behaviour/emotional needs, religion, relationships, medical/physical, communication, accommodation, domestic skills, personal finances, community participation, support, work, leisure and education. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take risks within a risk management framework. This helps to ensure they remain safe and that their independence is promoted. EVIDENCE: Residents are involved in their individual plans of care depending on their ability. The key worker carries out reviews and one to one discussions take place with the resident. Each resident has individual risk assessments depending on their needs and activities that they carry out. The risk assessments are detailed and are either reviewed annually or as the situation changes. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s rights are respected and routines in the home are flexible. Good contact is maintained between residents and their friends and relatives. A variety of food is offered to residents. EVIDENCE: The residents enjoy a range of activities at home, board games, snooker, billiards, carpet bowls, keep fit, karaoke, party nights. As the majority of the residents attend Day Centres during the week activities take place in the evenings and at weekends. Two members of care staff also take on the responsibility of organising activities. Residents also enjoy being out and about in the community; shopping, meals out, cinema, Social club and local pubs. Holidays are arranged as to what the residents prefer, some like a few days away and others have day trips. Regular contact is maintained with friends and family and visitors are made welcome at any time. The manager has been in post for the past few years as have the majority of the staff. This ensures a consistent approach with the residents. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 11 It was noted that staff are respectful towards residents and are aware of their individual rights in their daily lives. The menus showed that a variety of home cooked food is offered to the residents. A weekly menu is in place and there are choices for every meal. If residents do not like any of the food on the menu an alternative is made. Food is often a topic discussed in residents’ meetings and suggestions for changes are encouraged. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive good support from staff to ensure that their personal, physical and emotional needs are met. The service users health is protected by the medication policies. EVIDENCE: The care plans examined detailed the personal support needed and given. All residents in the home have their own General Practitioner, and residents attend appointments with either a member of staff or a relative. A health action plan is completed with the resident. Each resident receives support from staff to the level that they choose and require. Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. Examination of medication administration records showed that the procedures were being followed. However all medication is required to be on the marr sheets; such as food supplements. Medication prescribed as ‘prn’ should not be on marr sheets to be given ‘as directed’, more specific information is required. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints system, which residents can use if they are unhappy, have a grievance or dispute. Staffs have received training in adult protection to safeguard the residents from abuse. EVIDENCE: The home has a complaints procedure and policy in place and there is also a picture format for those residents who need it. There had been one complaint made to the home since the previous inspection, which was not upheld. Each resident has an individual copy of the complaints policy as different local authorities are involved. Staff work very closely with the residents and any concerns or grumbles are usually dealt with straight away. Residents are also reminded about how to make a complaint at residents meetings, which are held three monthly. The home has an adult protection policy and procedure in place. Staffs training files were examined which showed that training in ‘No Secrets’, the protection of vulnerable adults had been completed. A member of staff confirmed she had received the training. Information about adult protection is available to residents. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is attractive homely and comfortable for the people who live there. All areas were safe, well maintained. EVIDENCE: All areas of the home were comfortable, safe and well maintained. Resident’s bedrooms are individually decorated and furnished to suit their needs and wishes. The home in general was clean but some communal areas need deep cleaning. At the time of the inspection the manager was in the process of employing a domestic, to replace the member of staff who had left. Since the previous inspection some refurbishment and re decoration had been carried out in a lounge and some bedrooms. The medication storage area in Redwood needs to be moved from the kitchen and in Aspen the area is too small. Since the previous inspection ownership of the home has changed and having spoken to the management team and proprietor during the visit it was apparent that plans for major refurbishment are being put in place. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 15 Since the previous inspection a maintenance person has been employed and both the garden in the courtyard area and the paved area around the home were well maintained and tidy. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 16 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear leadership skills demonstrated by the manager and staff are adequately supervised. Recruitment policies and procedures are robust. EVIDENCE: The home has recruitment policies and procedures in place. Two staff files examined showed that the home’s policies are being followed and all the required documentation was in place. The files were well organised. The manager has compiled a comprehensive interview check list/questions to assist with staff recruitment. A resident is also involved when interviewing staff. Training files were examined which showed training had been carried out in Food Hygiene, ‘No Secrets’, Risk Assessments, Moving and Handling, First Aid and Fire Training. At the time of the inspection five care staff had achieved NVQ level 2 or above. More staff need to achieve NVQ level 2 for the home to reach the target of 50 . A further eight carers were working towards NVQ 2. The home has a formal supervision system in place with staff receiving supervision every eight weeks. The manager is available to carry out extra supervision sessions if needed. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 17 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager gives strong leadership and staff work as a team. Residents are protected by the health and safety policies and procedures. EVIDENCE: The home undertakes an annual audit of the service they provide. Residents, staff and relatives have been involved, completing questionnaires and attending in house meetings. A quality assurance audit had been carried out, involving residents, relatives and staff. From the outcome of the audit the manager had put an action plan in place. The area manager visits regularly and carries out an audit of the both of the building and documentation every month. The home has health and safety policies and procedures in place. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 18 The manager also undertakes an audit of the building every month and puts an action plan in place where required. Training files showed that staff have received training in health and safety. Residents receive good support from staff to ensure that their personal, physical and emotional health needs are met. The manager has been in post for a few years as have the majority of the staff. This ensures a consistent approach with the residents and staffs are aware of their individual needs and wishes. Residents meetings are held every three months, they are minuted and two of the residents sign to agree the minutes are taken by one of the residents. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 19 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 20 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. Standard YA20 Regulation 13 (2) Requirement All prescribed medication including food supplements is required to be in MARR sheets. Medication prescribed as ‘prn’ should not be on MARR sheets ‘to be given as directed’, more information is required. Timescale for action 31/03/07 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 YA32 YA20 Good Practice Recommendations More care staff need to undertake and complete NVQ level 2 or above in care. Medication storage areas in two of the bungalows need to be moved. The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 The Evergreens DS0000000055.V328718.R01.S.doc Version 5.2 Page 22 - 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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