Care Home: Evergreen

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What the care home does well The registered manager and staff make the home as comfortable and homely as possible. Residents are regularly consulted about decisions that effect them, and are supported to lead as independent a lifestyle as possible. Residents are able to be individual and make daily choices about how their day will be and are encouraged to become more independent, both in the home and the community with staff support. Residents said they were listened to and having no complaints. They felt able to complain if they needed to. Care plans, risk assessments and goals are all reviewed and evaluated. These reflect the residents` health and social care needs and give information about how the resident likes their care to be given.Residents are encouraged by the staff who know what food the residents like to eat and help them choose a healthy balanced diet. There is sufficient staff to meet residents` needs. There are good and appropriate relationships between staff and residents. What has improved since the last inspection? The home has worked hard to comply with the regulations and to meet all the requirements from the previous inspection in May 2007. The statement of purpose and the service users guide has been reviewed to include all the information required in Schedule 1 of The Care Homes Regulations 2001. A number of doors have been replaced with fire doors to comply with LFEPA recommendations that doors are fitted with an iridescent strip or be replaced. The kitchen and dining area has been refurbished and redecorated, which has made it clean and more homely. Documentation of records is being developed and is more through and has more information and detail. CARE HOME ADULTS 18-65 Evergreen 55 Barrow Road London SW16 5PE Lead Inspector Lynne Field Key Unannounced Inspection 24th April & 1st May 2008 12:00 Evergreen DS0000022799.V361982.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 Evergreen DS0000022799.V361982.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. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Address 55 Barrow Road London SW16 5PE 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) 0208-677-4273 0208 677 4273 info@janeshouseltd.co.uk Jane’s House Limited Mr Atmah Victor Barsati Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to residents of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of residents who can be accommodated is: 3 Date of last inspection 24th May 2007 Brief Description of the Service: Evergreen residential care home provides accommodation and support for up to three adults who have support needs due to enduring mental health difficulties. The service is located in a former private house, which is sited in a quiet residential street and is indistinguishable from other houses in the street. The home is situated close to shops and amenities and has good access to public transport. The registered provider owns the property and also owns two other small homes nearby. During the inspection it was evident that the home has been well maintained and offers a homely physical environment for residents. It is laid out over three floors. The ground floor has a staff office, kitchen/diner, and a large communal lounge area. To the rear of the home there is a large garden. The first floor has the service user bedrooms, a toilet, and a bathroom with shower facility and toilet. The upper floor has sleeping accommodation for staff. The home provide information to potential residents via their service users guide, statement of purpose and their website. Visits can also be made to the home. CSCI inspection reports are available in the communal areas. The registered provider said the current fees payable is in the range of £420.00p to £850.00 per week. There are additional charges made for toiletries, hairdressing newspapers and holidays. Evergreen DS0000022799.V361982.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 2 stars. This means the people who use this service experience good quality outcomes. This unannounced inspection took place over parts of two days in April and May 2008. We were joined on the second day by the Contracts Monitoring Officer, who came to monitor the service the home is providing to a resident they fund to live there. There was a full discussion about the expectations of the contracts monitoring officer and resident and what the home was actually providing. This needs to be explored more fully at the residents review so all have a clear understanding and an agreement of the outcomes for the resident. The registered manager returned a standard form, the Annual Quality Assurance Assessment (AQAA), to CSCI and this was used as part of the inspection. We checked records of the care plans, staff records and building maintenance records. The registered provider and three members of staff were present over the two days of the site visit to the home. A range of documents was examined and a tour of the building took place. We asked both residents if they would show us their bedrooms but both said they did not want to do this and this was respected. There were two residents living at the home on the day of the inspection and the home has one vacancy. We spoke to both residents. Residents said and indicated they liked living at the home and were happy there. Staff were observed to be competent and caring. Staff interaction with residents was observed to be knowledgeable and was conducted in a respectful manner. What the service does well: The registered manager and staff make the home as comfortable and homely as possible. Residents are regularly consulted about decisions that effect them, and are supported to lead as independent a lifestyle as possible. Residents are able to be individual and make daily choices about how their day will be and are encouraged to become more independent, both in the home and the community with staff support. Residents said they were listened to and having no complaints. They felt able to complain if they needed to. Care plans, risk assessments and goals are all reviewed and evaluated. These reflect the residents’ health and social care needs and give information about how the resident likes their care to be given. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 6 Residents are encouraged by the staff who know what food the residents like to eat and help them choose a healthy balanced diet. There is sufficient staff to meet residents’ needs. There are good and appropriate relationships between staff and residents. 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 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. Evergreen DS0000022799.V361982.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 Evergreen DS0000022799.V361982.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): 1,2,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information in the Statement of Purpose and Resident Guide has been revised to include all details required under Schedule 1. Resident’s needs are assessed by the registered provider before they move to the home and know that staff have decided that the home can meet their needs before they move there. Prospective residents and their relatives can come and look around the home and meet staff and have over night stays before they decide to move there. EVIDENCE: We looked at the statement of purpose and residents’ guide and discussed this with the registered provider who was at the home on the first day of the inspection. The home has up dated its statement of purpose and the service user guide since the last inspection in May 2007. One resident has moved on since the previous inspection. The two remaining residents have lived at the home for several years. Because the home has had no new residents since the last inspection it was not possible to fully assess Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 9 this standard. The home has an admission policy that it would follow, which includes obtaining a full assessment from prospective resident’s social workers as well as completing their own assessment. We were told by the registered provider that prospective residents would be encouraged to visit the home prior to admission to see if it was suitable for them and bring relatives and friends. It they thought they would like to live in the home they would come for a tea visit, then for a meal, building up to an over night or weekend stay. They would be given the statement of purpose and the service user guide to help them decide if the home would meet their needs. The home would use the visits to assess the prospective residents to ensure they could meet the resident’s needs. All the residents at the home had a contract of terms and conditions in their file. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 10 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): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are involved in planning their care with their key worker, the registered manager, appropriate professionals and family members. Residents are able to make decisions about their lives where possible and are enabled to be as independent as possible through risk assessment and planning. EVIDENCE: We looked at both residents care plans. Case files seen contained daily records, monthly evaluations, care plans and minutes of review meetings. These provided evidence that residents’ needs are assessed and kept under review. Each resident’s file had sections for any identified needs, the objectives and actions required to meet any identified needs. These are evaluated after six months. One resident, who is over sixty-five years of age, has her care plan evaluated every month. The care plan format has been reviewed to include Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 11 more information about resident’s needs and how they wanted their needs to be met. The registered provider said the key worker goes through the daily records and other information and this will be used to draw up a new care plan. The cares plans viewed by us had the signatures of the resident and the registered provider. One resident who spoke to us at length said they were involved in reviewing their care plan. We were told the residents had their care reviewed but the home was waiting for a copy of the review notes. The registered provider tried to contact the social worker during the inspection to ask for a copy to be forward to the home without success. There were risk assessments in place and there was information around issues to do with behavioural issues or what to look for if there was deterioration in the person’s mental health and what actions to take. The home has reviewed the format and it is included it in the care plan. Risks are reviewed annually or earlier if necessary. We met and spoke to both residents during the inspection. Both said they went out for walks or took part in activities they enjoyed. We saw one resident going out for a walk during both days of the inspection. This resident has a routine they like to follow each day. They go out every morning at about 6-30am. They told the inspector they liked walking around outside and spent time looking at things that interested them around where they lived. The registered provider and the residents all confirmed that they could come and go freely as they wanted to and they had front door keys. They said they would tell the staff when they were going out and where to and what time they hoped to be back by. One resident said they are able to choose when to get up/go to bed, and reported that they are regularly consulted and involved in decisionmaking. We were shown the minutes of the residents meetings that are held every two to three months. At the last meeting they looked at samples of wallpaper and paint because the kitchen / dinning area was going to be decorated. Residents meetings are when holidays and outings are discussed and agreed. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 12 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): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents engage in appropriate, enjoyable and fulfilling activities and mix with the general community. Residents are actively encouraged to keep in touch with friends and family and develop appropriate friendships. Residents’ rights and responsibilities are respected but the home needs to consider how it can encourage the residents to develop more independent living skills. The registered provider needs to make sure the home is working in line with current thinking of the placing authority to ensure the residents and home are all working towards the same outcomes. EVIDENCE: Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 13 Each resident has different daily routine and interests. One resident told us they go out to football matches and is trying to form a band. They said they had made a demo disc. They talked about themselves a lot and how they liked living at the home. They said they were not very good at cooking their own meals and needs to be careful about what they eat. They said they were much better than they were when they first came here. This resident has several girl friends that he sees regularly. He said they were just friends and one sometimes stays at the home for the weekend. The other resident spends more of their time indoors, but going out on their own for walks in the local area. We saw her several times walking around looking at things that interested her. As both the residents are individuals living in the same house, but they are not necessarily friends, they have their own ideas around what sort of holiday destination they may like and this is being explored with residents and the multi- disciplinary team. All the residents either do their own shopping or are supported to shop with a carer accompanying them. Residents can cook for themselves and if needed will be supported in the kitchen. The home does not have a menu and residents decide on the day what they want to eat and are encouraged to eat a healthy diet. One resident cooks most of her meals but is very limited in what they will eat. At the time of the last inspection they were trying to loose weight to assist mobility and is now able to go where she wants to. One resident told us they were not very good at cooking their own meals and did not want to cook. They said they need to be careful about what they eat. They said their GP had given them a food chart, so they know what they can eat. The registered provider said they have tried to educate and raise the awareness of residents on nutritional values and have tried to improve the daily menu. We were told they try to get residents to try new types of food. The home does not have a weekly programme as such because all activities are very much centred on individual resident’s wishes and choices. We were told there was a routine around some aspects of the home, i.e. residents had particular days when they do their washing with the support of staff if needed but they are sometimes very reluctant to do these chores. A member of the local authority contact monitoring team who was monitoring residents in both homes contacted us during the inspection. We met them at the sister home for part of the visit. They shared their concerns with us and the registered provider about the residents lacking motivation to develop independent living skills. There was a discussion with the registered provider about the expectations of what the service was providing and what it was perhaps now being expected to provide. It has been some years since both residents moved to the home and care in the community for people with mental health issues has changed. We discussed how now the expectation is Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 14 that for most residents this would be a transient period of time spent in a residential home. The emphasis has moved to rehabilitation through developing and maximising the residents functioning potential to help them live more independent lives in the community. In our discussions it was acknowledged this would not be suitable for all residents but the home could do more to encourage them to develop daily living skills that could help them move on to independent living scheme if it was felt this is right for the residents. Both residents are very comfortably settled, having lived at the home for many years and it provides all they need. One resident is over sixtysix and is very set in their ways and has set idea’s about what they want to do and eat each day and to move her to another setting could be very unsettling. The registered provider needs to look at how staff can encourage residents to be motivated to develop more independent living skills. The issues and expectations of the placing authority, residents and home need to be fully discussed with each residents at a review of the service, so all are clear what outcomes they are working towards. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 15 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): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in ways they prefer and their health and emotional needs are met. Residents are protected by the homes policies and procedures for dealing with medicines. Residents are consulted about their final wishes and the home is sensitive about how it does this. EVIDENCE: The residents’ files and care plans give information about residents’ health needs. Staff continue to support the residents to maintain their physical and emotional health. One resident has moved on and there are two residents in the home who are fairly independent with regard to personal care. One resident who developed a mobility problem, had been assessed by the occupational therapist and has been provided with bathing equipment. To help with their mobility, they had been encouraged to lose weight and this has Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 16 continued to be monitored on a weekly basis and is now stable. Staff support residents with personal hygiene by encouragement rather than providing direct physical care. We looked at both files and saw residents are in contact with various health professionals including care coordinators, psychologists and social workers. The registered provider and the resident we spoke to during the inspection both said they felt that they were well supported by other professionals and could discuss problems or issues with them if they needed. The registered provider said one resident who needed to see the chiropodist urgently but was reluctant to do so was given the option of paying for their treatment or going to the local surgery. This helped them make an informed decision about their treatment and they chose to go to the local surgery. The home has gathered information around residents’ wishes and views regarding aging and death and this was seen on file. One resident is self-medicating. Risk assessments are on file. The home have introduced a running total for the amount of medication they have left for each resident to ensure that they have the correct amount and this corresponds to the medication signed for from the pharmacy. We checked both residents’ medication with the registered provider and it was found to be correct. All medication coming into the home and medication that is not required is recorded in the medication book. Medication not needed is retuned to the pharmacy for disposal and this is recorded in the book. One resident told us they were so much better now than when they came into the home and they were taking their medication regularly. They said they were “very lucky to live here”. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 17 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. Residents said they were listened to, and had no complaints. The home has an appropriate complaints procedure and the home has a copy of the local authority adult protection guidelines. EVIDENCE: The home has a complaints procedure. There have been no recent complaints. The complaints book is on display in the hall for residents or visitors to look at or write in. The home has information on the protection of vulnerable adults. We saw a copy of the multi-agency procedure that the home obtained from the local authority. We spoke to the staff on duty and they said they would contact the registered provider if they were suspicious or were told of any abuse taking place. Staff said they had training in adult protection May 2006. The registered provider said the residents were encouraged to speak about any complaints they might have at residents meetings. Both residents told us they did not have any complaints but would speak to the registered provider or their key worker if they did. The home has a policy regarding the protection of the resident’s finances. As part of the inspection we checked the residents’ money files and they were in order. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 18 The registered provider told us that residents meetings are held every two to three months. They have three small homes, two in the same street so they have one residents meeting for the residents from all the homes. We saw copies of minutes of the meetings and noted that residents are encouraged to speak out about any concerns they may have. These covered a range of issues including meals, answering the phone and taking messages, planning activities, trips out, and the garden. One resident said he went to the meetings and felt able to say what he wanted. The member of staff we spoke to confirmed the resident’s have meetings that are held in the home. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 19 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): 24,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The kitchen and dining area have recently been redecorated and refurbishment and the residents have a comfortable, safe, clean home, which is well adapted to their needs. EVIDENCE: The home is situated in a Victorian house in a residential street. We were given a tour of the home. There is a communal sitting room with French doors leading to a pleasant and well-maintained garden. The kitchen with dining area to the rear of the ground floor has been refitted with new kitchen units and worktops and both areas have been redecorated. This has greatly improved the kitchen and dinning area and it now looks clean and homely. On the second day of the inspection the kitchen door and a number of doors though out the house were also being replaced with fire doors to comply with the fire service recommendations. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 20 There are three residents’ bedrooms on the first floor, a bathroom and WC and a separate WC on the same floor. The home is furnished in a homely and attractive manner, with an upright piano and a TV in the sitting room. The home has pictures, ornamentation, and plants in all the communal areas. The effect is very homely, with an atmosphere as a family home. Neither resident wanted us to show us their bedrooms despite them both being happy to speak to us in the communal areas. One resident’s bedroom has room for a settee, which they had just purchased before the last inspection in May 2007. This resident has a telephone and a computer in their room and had applied to have an Internet connection installed. They have a small fridge and a kettle and are able to make themselves and their guests snacks and drinks independently. They told us they sometimes had a friend to stay and let them have their bed and they slept on the settee The bathroom has a large bath with a bath seat in it and a grab rail for the resident who has some mobility problems. This was put in after the resident had an occupational assessment when they were experiencing difficulties getting in and out of the bath safety by herself. This resident is very independent and liked to do as much for them selves as possible. Both residents told us they were very happy living in the home and could not imagine living anywhere else. The contracts manager for one resident was present on the second day of the inspection and we discussed improving the bathing facilities for the resident’s service by installing en suite facilities in some of the bedrooms and how the service could be improved. The house has a cellar where food and other items are stored. This was generally well set out with items stored on shelving. The fridge in the kitchen was replaced as required. The home has fitted a thermostat on to the hot water cylinder outlet pipe, so hot water to all the hot water taps are controlled to ensure that hot water delivered to the taps is not above 43 degrees centigrade. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriately trained staff meets the residents’ individual needs. The recruitment procedures followed are safe, thorough and comply with legal requirements. EVIDENCE: We looked at the staff rota and confirmed the number of staff on duty was correct. The home has one member of staff on duty during the day and one sleeping member of staff at night. The deputy manager, who lives upstairs, works as the sleeping night worker. Extra staff are asked to work to act as an escort or the registered provider will cover the home if a resident needs to be escorted to an activity or attend an appointment for some reason. The registered manager was included on the rotas inspected and he lives at the home. The inspector spoke to the one member of staff who was on duty at the time of the inspection. They said the management of the home were very supportive and confirmed they had gained NVQ level Two. They said they were working Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 22 towards NVQ level 3. They said all staff of the home had taken a course in Nutrition and Health run by Croydon College. They said they had been on a number of other courses such as POVA and Medication and Mental Health. They said they had regular supervision and the files inspected contained evidence of regular supervision and supervision notes that had been signed by the member of staff and the registered manager. There is a long-standing staff group who know the residents well and so are able to give them consistent care. Two staff files were examined. These included copies of the application forms, two written references, a signed copy of their contract stating terms and conditions and identification. All files checked had CRB checks. The registered provider said they would not start a member of staff to work in the home unless they had been CRB checked. At the previous inspection we noticed several staff that have been employed by the home for a long period of time, had CRBS that were three or more years old. To keep them up to date the home has renewed these. All staff working at the home has qualified to level 2 NVQ or above. There were copies on the staff files of the certificates issued for the courses staff had attended. At the last inspection although there were copies of the induction training that was given, this was only about the home and health and safety issues and did not fully comply with “Skills for Care” level of induction. This was said to be needed to be addressed but because there have been no new staff since the last inspection so the home’s induction procedures could not be fully checked at this inspection and will be checked at the next inspection and this has been left as a requirement. The registered provider is very enthusiastic about encouraging staff to develop new ways of thinking and passes on any information and training she attends to staff. She had recently attended a seminar run by Well London about Mental Health and well being and had spoken about this in staff meetings and at residents meetings. Six training course/lectures, such as Handling Aggression, Depression and Schizophrenia have been carried out to update knowledge and improve the skills of the staff. We distributed copies of the staff survey for CSCI to staff at the inspection but none have been returned at the time of writing the report. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 23 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. Resident’s benefit from a well run home and management is experienced in supporting people with mental health needs. Systems are in place to address Health & Safety issues. EVIDENCE: The home has just developed quality assurance monitoring forms they are giving to Health Professionals and Care Managers. The home does not carry out surveys of relatives that visit the home but they have completed a number of self-monitoring reports and sent a copy to the CSCI office. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 24 One resident told us he did not like filling in forms and said he did not want to complete the residents survey for CSCI. We gave the second resident a copy of the survey but this has not been returned at the time of writing the report. Both residents said they liked living at the home and the registered provider was good. We distributed copies of the staff survey for CSCI to staff at the inspection but none have been returned at the time of writing the report. Staff told us the homes management was very caring and they looked after their staff. The home had a policy on health and safety and the inspector viewed health & safety records held in the home. There were copies of regular checks at the required at intervals, by external contractors, for servicing the fire safety system, the boiler, central heating system and the emergency call system. Certification was in place regarding the Landlord’s Record of Gas Safety, Portable Electrical Appliance testing, and Certificate of Electrical Installation. A new fire alarm system was installed in May 05, of the type of system was in line with the recommendation of the Fire department and a fire risk assessment and floor plan was completed. Records showed that regular checks of the fire alarm call points were made and that fire drills were conducted. A number of doors through out the home were being replaced on the second day of the inspection to comply with LFEPA recommendations that doors are fitted with an iridescent strip or be replaced. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 3 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 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement 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 YA11 YA16 Refer to Standard Good Practice Recommendations The issues and expectations of the placing authority, residents and home need to be fully discussed with each residents at a review of the service, so all are clear what outcomes they are working towards. Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Evergreen DS0000022799.V361982.R01.S.doc Version 5.2 Page 28 - 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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