Care Home: Evergreen

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What the care home does well The home provides a warm, homely and pleasant environment that is furnished and decorated in a style that is age appropriate. Peoples healthcare needs are well met with staff adopting a proactive approach to obtaining the assistance of external professionals to promote people health and wellbeing. Aids and adaptations are provided so that the independence, choices and dignity of people were being respected and promoted. Regular checks of equipment were being carried out to ensure that they are fit for purpose. Personal care is provided to suit peoples personal preferences. Care plans include detailed information about peoples decisions such as, instructions for staff to apply make-up. The home has a policy of open visiting and staff were observed welcoming visitors and chatting with them. Staff were observed whilst carrying out their duties. They were friendly and courteous offering assistance where necessary. It was pleasing to note that staff appeared to have developed good relationships with people in the home and that they took time out for socialising. An interesting range of meals are provided; good choices are given and staff were observed listening to a request and confirming that the meal would be cooked. This suggests that people are offered a nutritious and varied diet that suits their personal preferences. Although there is a small staff turnover the home enjoys the stability of a number of long serving staff. A stable staff group provides people with continuity of care. A varied range of activities both in the home and externally are offered to people. Recordings are maintained of those who participate to enable staff to review the programme in respect of meeting peoples aspirations. Shortly prior to the inspection visit nine people sent completed questionnaires to us. All provided positive feedback and extra comments were made about the high standards of care, the hygiene of the home, the meals and the good support provided by staff. What has improved since the last inspection? Twelve requirements were made as a result of the last inspection; ten of them had been addressed and another had been partially met. This indicates that the home views inspections as being a positive experience and has made improvements that will benefit the people living there. The requirements concerning care plans had been addressed. They provide very detailed information about a persons needs and what staff need to do to maintain peoples preferred lifestyle. People who live in the home had requested a change of time for serving breakfast. Staff responded positively and the time has been changed to suit peoples daily living routines. On the day of the visit the manager was in the process of developing audiocassette versions of the statement of purpose and service user guide. This will assist people who have vision impairment in understanding the content of the documents. Care plans are commenced as part of the pre-admission assessment. This is to assist staff in having an early understanding of smaller details, which may be quite important to the person. An activity organiser has been employed to work three days per week. The activities programme for the following week is developed following negotiations with people who live in the home. The ground floor bathroom wash hand basin and toilet have been replaced to ensure the room is pleasant and that the equipment is fit for purpose. New lighting has been installed in the lounge and dining rooms that enables people to see more clearly and prevents the risk of accidents from occurring. All bedrooms now include a television. This initiative provides people with entertainment whilst enjoying the privacy of their own room. Newly recruited carers are expected to complete a formal induction programme to provide them with the basic skills to work within the care sector. The manager has introduced a system of weekly audits of the medication system. This is to ensure that staff practices are satisfactory in ensuring that people receive their medications as prescribed. What the care home could do better: Bedroom door locks should be fitted to enable people to maintain their privacy whilst residing in the home. The frequency of staff formal supervisions needs to increase to ensure that each employee has a meeting at least six times per annum. It is recommended that written information about the fee rate, how it is calculated and details of any services that are not included within it be developed. This should form part of the service user guide to give prospective users of the service full information about the home. It is recommended that the complaints procedure is made available in audiocassette format for the benefit of people who are visually impaired. It is recommended that a sluice room be incorporated into the plans for extending the premises. It is recommended that recordings should be made of the action taken as a result of shortfalls identified from the quality assurance process. This is to evidence that improvements are being made for the benefit of people who live there. CARE HOMES FOR OLDER PEOPLE Evergreen 526 Church Road Yardley Birmingham West Midlands B33 8HT Lead Inspector Unannounced Inspection 22nd January 2008 10:15 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 Evergreen DS0000016747.V358236.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. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evergreen Address 526 Church Road Yardley Birmingham West Midlands B33 8HT 0121 783 2080 0121 783 2080 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) Mr David Thompson Mrs Rebbeca Hobbins Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2007 Brief Description of the Service: Evergreen is located in a quiet residential road in Old Yardley approximately four miles from the city centre. There are good public transport services close by and the home is within easy walking distance of local shops and community facilities such as Yardley old church and park. The accommodation is a converted three storey detached house offering accommodation to 14 elderly residents. The second floor is used solely by staff as an office and sleep-in facilities. The accommodation comprises of three double and eight single bedrooms spread over the ground and first floors. A stair lift is available for ease of access. Bedrooms vary in size and are all comfortably furnished, includes a wash hand basin and are individualised by the occupant. There are toilet and bathing facilities on both floors. Communal rooms are situated on the ground floor and consist of a large lounge leading to a wellmaintained rear garden and an adjoining pleasant dining room. Both rooms are nicely decorated and furnished. The laundry, kitchen and staff toilet are located on the ground floor. The service user guide does not include the fee rate or details of the services that are not included within it. This needs to be addressed to enable prospective users of the service to make an informed decision at an early stage. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know that the fieldwork visit would be carried out; this is to enable the inspector to obtain an accurate picture of the standards of the services provided. On the day of the visit, the home had twelve people living at the home. The manager provided assistance with the inspection process. At the conclusion feedback was given to the manager. No Immediate Requirements were made. Information was gathered from speaking with people who reside at the home and staff. Care, health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was carried out. Two of the three care plans reviewed were case tracked. This involves obtaining information about individuals’ experiences of living at the home. This is done by meeting with or observing people, discussing their care needs with staff, looking at care plans and focussing on outcomes. Tracking peoples care needs and how the care is delivered helps us to understand the experiences of those people and the standards of care provision. The inspector spent time in the dining room and lounge carrying out an assessment about how staff spent time with people who live in the home. It included how staff communicated with them, what they did and how it affects the daily lives of people. This is referred to in the body of the report as SOFI (short observational framework for inspection) in the section concerning daily life and social activities. Prior to the visit the home had completed the annual quality assurance assessment and returned it to us. The information within the document advised of what the home does well, improvements made during the last 12 months and what the home would like to further improve. This provided details that contribute to the inspection process and highlights areas that may be explored during the fieldwork visit. A number of people who live at the home were requested by the inspector to complete a questionnaire. These give personal opinions about the services provided and are included in this report. The focus of inspections undertaken by us is based upon the outcomes for people who live in the home and their views about the services provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and aspects of service provision that need further development. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 6 What the service does well: The home provides a warm, homely and pleasant environment that is furnished and decorated in a style that is age appropriate. Peoples healthcare needs are well met with staff adopting a proactive approach to obtaining the assistance of external professionals to promote people health and wellbeing. Aids and adaptations are provided so that the independence, choices and dignity of people were being respected and promoted. Regular checks of equipment were being carried out to ensure that they are fit for purpose. Personal care is provided to suit peoples personal preferences. Care plans include detailed information about peoples decisions such as, instructions for staff to apply make-up. The home has a policy of open visiting and staff were observed welcoming visitors and chatting with them. Staff were observed whilst carrying out their duties. They were friendly and courteous offering assistance where necessary. It was pleasing to note that staff appeared to have developed good relationships with people in the home and that they took time out for socialising. An interesting range of meals are provided; good choices are given and staff were observed listening to a request and confirming that the meal would be cooked. This suggests that people are offered a nutritious and varied diet that suits their personal preferences. Although there is a small staff turnover the home enjoys the stability of a number of long serving staff. A stable staff group provides people with continuity of care. A varied range of activities both in the home and externally are offered to people. Recordings are maintained of those who participate to enable staff to review the programme in respect of meeting peoples aspirations. Shortly prior to the inspection visit nine people sent completed questionnaires to us. All provided positive feedback and extra comments were made about the high standards of care, the hygiene of the home, the meals and the good support provided by staff. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? Twelve requirements were made as a result of the last inspection; ten of them had been addressed and another had been partially met. This indicates that the home views inspections as being a positive experience and has made improvements that will benefit the people living there. The requirements concerning care plans had been addressed. They provide very detailed information about a persons needs and what staff need to do to maintain peoples preferred lifestyle. People who live in the home had requested a change of time for serving breakfast. Staff responded positively and the time has been changed to suit peoples daily living routines. On the day of the visit the manager was in the process of developing audiocassette versions of the statement of purpose and service user guide. This will assist people who have vision impairment in understanding the content of the documents. Care plans are commenced as part of the pre-admission assessment. This is to assist staff in having an early understanding of smaller details, which may be quite important to the person. An activity organiser has been employed to work three days per week. The activities programme for the following week is developed following negotiations with people who live in the home. The ground floor bathroom wash hand basin and toilet have been replaced to ensure the room is pleasant and that the equipment is fit for purpose. New lighting has been installed in the lounge and dining rooms that enables people to see more clearly and prevents the risk of accidents from occurring. All bedrooms now include a television. This initiative provides people with entertainment whilst enjoying the privacy of their own room. Newly recruited carers are expected to complete a formal induction programme to provide them with the basic skills to work within the care sector. The manager has introduced a system of weekly audits of the medication system. This is to ensure that staff practices are satisfactory in ensuring that people receive their medications as prescribed. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 8 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 DS0000016747.V358236.R01.S.doc Version 5.2 Page 9 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 Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 10 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 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are considering using the service are supplied with adequate written details about the home to enable them to make an informed decision. Pre-admission assessments are good; this means that the home is able to demonstrate that it can meet individuals’ needs at the time of admission. EVIDENCE: The statement of purpose and service guide were reviewed and noted to contain adequate information to assist people in making decisions about the home. The manager needs to incorporate into the service user guide or accompany the document with written information about the fee rates. This should include details about any contributions made by other organisations and clearly state which services are not included in the fee rate. During the visit the manager commenced work in producing both documents in Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 11 audiocassette to assist people who have visual impairment in understanding them. This is viewed as being good practice. The pre-admission assessment recordings were checked for the two latest admissions. They provided enough information to enable senior staff to make a decision about the home ability to meet the persons’ needs. Following conclusion of the inspection a sample of the revised pre-admission assessment tool was provided by the manager. The document had been extended to seven pages and includes many further questions to explore such as likes and dislikes, daily routines and sleep pattern, hobbies and interests personal care needs and religious requests. The new tool will provide staff with a good framework for completion of the more detailed care plan that is developed shortly after admission. The tool is a good improvement. One of the two admissions had visited the home three times before making a decision to move in. The manager advised that if she determines that the home could not meet the persons needs she would not offer a placement. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 12 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 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ health and personal care needs are well met; this is evidenced in the care planning process. The management of medications ensures that people receive their prescribed medications appropriately. EVIDENCE: Each person has a written care plan, which is completed shortly after admission. The pre-admission assessment provides staff with the basis to record more detailed information about the person. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff to enable them to maintain their needs. Three care plans were seen including the latest admission and people with differing illnesses or needs. The files contained good information about the individuals’ preferences and how they wish to be cared for in order to lead their preferred lifestyle. Care plans covered many areas including such things as preferred time of retiring and likely time of getting up. The care plans Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 13 provide information about the persons needs and these are used for the basis for more detailed information supplied in the Daily Care Plan Record. The Daily Care Plan Record gave staff very detailed instructions about how individuals wished to be cared for. For instance ‘no soap is to be used on her face, only facial wipes’, ‘horlicks on going to bed’, ‘assistance to be given each morning in applying her makeup’. Regular reviews are carried out to make sure that the written guidance for staff to follow is up to date. Risk assessments have been carried out where relevant in order to minimise the risk of injuries as far as possible. On the occasions when a hoist is needed the sling size that is most suitable for the respective person has been recorded. People’s healthcare needs were being well met. There was ample evidence of when external professionals had visited and what action staff need to take to promote peoples health and wellbeing. One person who was prone to urinary tract infections was being well monitored by regular testing. This will enable staff to act quickly when a possible infection is developing. The home should be commended for this practice. Another person who had been having a number of falls was investigated and a possible cause had been identified. Nutritional assessments were completed as well as pressure ulcer risk assessments. Where a weight loss had been identified appropriate referral had been made to the dietician. Staff appeared to be quite diligent about ensuring that peoples’ health needs were being met. A very ill person and her family had made the decision that she would like to remain in the home. There was documentary evidence that the support of many professionals had been enlisted to make the remainer of her stay as satisfying as possible. Some improvements to the care plans were needed to ensure that they provide full information: • Some entries had not been signed and dated by the author • When short term illnesses such as chest or urinary tract infections occur a care plan need to be developed. This system will also assist in identifying trends • Some files did not indicate how often, method or the preferred time of day for bathing • Where possible the frequency of visiting professionals should be recoded such as chiropodists • It is advised that some of the entries in the Daily Care Plan Records could be transferred and included as part of the actual care plan. Staff were observed being polite and courteous and there was a relaxed and friendly atmosphere. Personal care was delivered in the privacy of the Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 14 persons’ own bedroom or a bathroom. Shared rooms have portable screens for staff to use to ensue peoples privacy and dignity were maintained. During the visit a group discussion was held and the following comments were made. “It is absolutely fabulous, you get looked after, can have a bath when you want it, I like mine in the evenings and that’s when I get it”. The procedure for ordering, storing, recordings and disposal of medications were reviewed. The systems appeared to be robust and ensured that people receive their prescribed medications at the correct times. The medications of the people whose care plans were seen were audited and found to be correct. The manager was advised to ensure that all handwritten instruction by staff should be counter signed by another to confirm that the instructions are accurate. The manager carried out regular audits of the medications to ensure that staff practices are acceptable. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 15 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities meet the needs and expectations of people to enhance the quality of their lifestyles. The meals are varied and nutritious and ample choices are offered. EVIDENCE: There were a number of activities on offer in the home including, quizzes, board games, cards, bingo, sing-a-long, dominoes, films, manicures, knitting, baking, arts and crafts, group discussions and one to one talks. Outings included visiting the nearby church, walks, visits to the park, pantomimes and pub lunches. One person goes to a day centre. People are asked about their spiritual needs and staff ensure that they are met. On the day of the inspection a number of people went for a walk whilst a carer sat with a group of people who did not want to go out, socialising with them. The conversation was light and relaxed. One person made a request for a Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 16 particular meal to be cooked and served; the carer said that she would “Sort it out”. People appeared to be happy in their environment. The activities provided are documented and the names of those who had participated were recorded. This information can be used to monitor peoples’ preferences. People advised that they go to bed and rise when they wish to and they can have visitors at anytime to suit them. People said, “We go to the shops, play bingo and quizzes, about seven of us go to church”. “On New Years Day we had a three course meal, candles, crackers and wine, it was a good day, we had a little sing-along”. Residents meetings are held regularly and minutes recorded. The minutes of previous meetings indicated that people who live in the home are able to influence the way in which it operates. The meal menu suggested that people are encouraged to have a healthy and balanced diet. The main meal of the day is served at lunchtime and was observed to be a pleasant experience. The dining room was attractively presented with linen tablecloths and napkins. There were three choices for the main course. One person had chosen a meal she had not had before but did not enjoy it. She was offered alternatives and staff provided a meal that the person said she enjoyed. Staff provided appropriate and discreet assistance. Someone commented about the meal, “I chose my lunch but I didn’t like it because I hadn’t had it before so staff gave me pork and potatoes and I thoroughly enjoyed it”. During lunch and afterwards when people were seated in the lounge the inspector carried out short observational framework for inspection (SOFI). This entailed what people were doing and how staff interacted with them and the impact this had. No one had been informed beforehand that it would be carried out. The overall response was positive. Staff were present throughout the whole process which lasted for two hours. Good interactions were noted and staff confirmed what they were going to do to assist people. Staff made attempts to involve everyone and a general friendly and relaxed atmosphere was noted. Staff were also observant of peoples routines, habits and needs. Staff engaged people in conversation during the whole time, this is viewed as being good practice. When people returned from their walk they joined in with the group discussion. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 17 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ opinions are listened to and if a complaint is made the systems in place suggest that it would be dealt with appropriately. The arrangements in respect of adult protection suggests that people are protected from risks of abuse. EVIDENCE: The home has a written complaints procedure that provides people with information on how to make a complaint and the response they can expect to receive and when. It is recommended that the procedure be made available in audiocassette for the benefit of those who have visual impairment. Neither the home nor us have received a complaint since the last inspection. The home has an extensive written policy about adult protection and also uses Birmingham City Council multi-agency guidelines. No issues have been raised and staff had received training in how to respond if abuse is suspected. Evergreen DS0000016747.V358236.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, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A homely, clean and pleasant environment is provided for people to live in where they appear to feel safe and secure. EVIDENCE: The premises were well maintained warm, homely and inviting. Repairs and maintenance are carried out when necessary to promote a safe environment for people to live in. Some works had been carried out since the last inspection. These include installation of new wash hand basin and toilet in the ground floor bathroom, new lounge and dining room lighting and all bedrooms have been supplied with a television. All of the communal areas were visited, a sample of bedrooms were also looked at. The lounge gave a welcoming appearance; there was ample soft furnishings and evidence of numerous board games and videos for people to Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 19 make use of at their leisure. The home has a secluded garden that includes a paved area for ease of access; it was very neat and appealing. There were communal bathrooms on each floor offering assisted bathing and a choice of bath or shower. Toilets were strategically located throughout the home. There were appropriate adaptations in the home including a ramped access into the front of the home, grab and support rails, a call system, bath seats, hoist and a stair lift. Bedrooms were noted to vary in size and layout; they were tidy and personalised to the extent of the preference of the occupant. Each room has a lockable facility to enable people to safely store financial and personal items. None of the bedroom doors included suited locks to promote peoples privacy; this shortfall needs addressing. The laundry room is small but adequate. Each person had their own basket to store their clean items of clothing. The home uses alginate (dissolvable) bags for soiled linen to ensure that hygienic methods are employed. The size and layout of the current premises does not permit the installation of a mechanical sluice for cleaning commode pots. The manager was advised that one should be fitted as an integral part of the extension plan. Evergreen DS0000016747.V358236.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home maintains adequate staffing levels to meet the individual needs of the people living in the home. Staff undertake training to give them the knowledge and skills to perform their roles competently. EVIDENCE: Review of the latest staffing rotas suggested that there were adequate numbers of staff on duty to meet the needs of the current client group. Some people required very little assistance to maintain their independent living skills. There were two carers on duty during the daytime hours and a senior member of staff. Night time staff consists of two people to assist people in going to bed and getting up the following morning; during the quiet period one of the two staff changes to a sleep-in basis. Staffing of the kitchen was between 09:30 and 14:30 each day and the home also employed a housekeeper. This permits the carers to carry out their designated roles in providing personal care and support. Checking of three staff personnel files including the latest recruit revealed that the home adopts a robust recruitment process. All relevant checks are carried out before the applicant is permitted to commence employment. This indicates that senior staff ensures peoples safety and wellbeing. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 21 Some comments made during the visit were, “Staff are great, they are always there the middle of the night, anytime”. Newly recruited staff undertakes the homes own induction programme followed by an in depth one that reflects the contents of the Skills For Care syllabus. This ensures that all new staff were being provided with the basic skills to work in the care sector. The home enjoys a core of staff who have been employed for a long time; this provides good continuity of care for the people who live there. Of those employed, 90 have successfully completed NVQ level 2 and staff are encouraged and supported in continuing with higher level training. The manager uses an annual chart to record staff training; there appeared to be a rolling programme in order to capture all staff. Mandatory training included moving and handling, fire safety, medications, adult protection and health and safety. Further training is offered that includes infection control, nutrition, tissue viability, bereavement, dementia care, epilepsy and managing aggression. This indicates that staff were being supplied with the knowledge and skills to meet peoples specialist needs. Evergreen DS0000016747.V358236.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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures that continual improvements are being made for the benefit of those who live there. Health and safety arrangements are robust and protects people from risks of injuries. EVIDENCE: The manager has a wealth of experience and staff advised that she is “Very good and supportive”. Someone who lives in the home said, “She’s lovely”. It was evident that there were positive relationships between the manager, people living in the home and staff. A deputy manager is employed who provides support to the manager. Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 23 There are plans to extend the building; this will increase the occupancy and upgrade shared rooms to single status. The works will include installation of a shaft lift to improve peoples’ access between floors. It is envisaged that the work would be carried out in two stages to reduce the disruption to the homes occupants. The homeowner carries out unannounced monthly visits to check that the home is being run appropriately. He compiles a written report, which is given to the manager. Questionnaires are regularly given to people who live in the home for them to complete. The manager collates the responses into percentages. The previous report indicated that people are very happy with the services they receive. The manager advised that where a shortfall was identified action is taken to rectify them. Advice was given that the action taken should be documented to evidence that the home has addressed them. Prior to the inspection we received nine questionnaires from people who live in the home. All provided positive responses and some gave praise in some areas. These were, the standard of care that they receive, good hygiene throughout the home, tasty meals and the helpfulness of staff. The home holds small amounts of peoples’ personal monies. The storage and financial transactions are good; this ensures that people are safeguarded from financial abuse. The manager audits the accidents each month in order to identify any trends and where possible takes appropriate action to reduce the incidents. All relevant checks and servicing of equipment are carried out to ensure they are fit for purpose. The fire alarm and emergency lighting systems are regularly tested and the findings recorded to protect people fro harm in the event of an emergency situation. The arrangements appear to protect people living in the home and others from risks of injuries. Evergreen DS0000016747.V358236.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 2 X 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 3 X 3 X X 3 Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 13(4)(c) Requirement All recordings made in care plans must be dated and signed by the author to validate the entries. Short term care plans must be developed for people when they develop conditions such as urinary tract or chest infections. This is required to ensure that staff have appropriate written guidance at all times and to monitor peoples trends with these conditions. 2. OP24 12(4)(a) Suited bedroom door locks must be fitted that can be overridden by staff in the event of an emergency. These are required to permit people to have full privacy within their own room. The frequency of formal staff supervisions must be increased to a minimum of six times a year. This is required to ensure that staff have the competency to carry out their riles affectively. N.B. The designated timescale Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 26 Timescale for action 31/03/08 31/08/08 3. OP36 18(2) 30/04/08 made at the previous inspection for addressing this requirement, had not expired and is therefore repeated. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations It is recommended that the complaints procedure be produced in audiocassette format for the benefit of people who have visual impairment. It is strongly recommended that a sluice facility be installed at the home when practically possible. It is recommended that any action taken where shortfalls are identified within the quality assurance programme is recorded. 2. 3. OP26 OP33 Evergreen DS0000016747.V358236.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 DS0000016747.V358236.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. 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