Care Home: Eversfield

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What the care home does well The care home is an elegant building. All areas are kept very clean and are well maintained. It is tastefully decorated and furnished to an extremely high standard. Attractive and well-maintained gardens and grounds surround the home. Residents` physical and mental health needs are well met with access to health professionals. Residents value the opportunity to be themselves, to be private if they wish or to have activities that they can join in with if they choose. People who use the service are offered a varied, nutritious and well balanced diet in an attractive and well-equipped dining room. There is an open and friendly atmosphere with good interaction between residents, staff and visitors. Resident`s said their visitors are always made welcome in the home. Residents know there are people who they can talk to about any concerns, who will listen and who will take action to improve the situation. Robust recruitment processes ensure that people living in the home are being cared for by properly vetted staff. The home meets the recommended target for staff trained to National Vocational Qualifications (NVQ) level 2 or above. What has improved since the last inspection? Assessment documentation is in place to ensure the individual needs of residents are clearly identified before they move in. This ensures peoples needs can be met by the home. Records show that residents` care plans are now being reviewed at least once a month; they are being updated to reflect the individuals changing needs and any current objectives for health and personal care. Evidence further shows that changes are clearly being actioned to the benefit of the people receiving care. Assessments of any risks to residents are being carried out, including the risks associated with the use of electrical equipment such as electrically operated beds. This ensures their health and welfare is better protected. Residents meetings are now taking place and people living in the home are regularly being consulted about their social interests and ideas for menu planning. Arrangements are made to enable individuals to take part in local, social and community activities, which ensures the lifestyle experienced in the home matches peoples expectations and preferences. To ensure that the home is managed and conducted to promote and make proper provision for the health and welfare of people living there, all windows where there was previously a risk of someone falling out, have been restricted to eliminate any potential for harm. The home`s fire doors, designed to close automatically to protect residents in a fire emergency, are now being monitored by senior staff and the practice of wedging them open has ceased. The manager has firm plans to publish and supply to residents and other stakeholders, including the CSCI, the results of any surveys regarding the quality of the service provided at Eversfield. CARE HOMES FOR OLDER PEOPLE Eversfield 56 Reigate Road Reigate Surrey RH2 0QP Lead Inspector Marion Weller Key Unannounced Inspection 25th June 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eversfield DS0000064751.V365322.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. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eversfield Address 56 Reigate Road Reigate Surrey RH2 0QP 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) 01737 229899 01737 229898 Jane.Baillie@efhl.co.uk www.efhl.co.uk Elizabeth Finn Homes Ltd Vacant Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2007 Brief Description of the Service: Eversfield is owned by Elizabeth Finn Care and is managed by Elizabeth Finn Homes Limited and is one of a number of care homes managed by the organisation. The home is a large converted Victorian house situated in Reigate, Surrey. The property has been extended to accommodate up to 35 older people in single bedrooms, each with en-suite facilities. The service provides an elegant and very comfortable environment and there are extensive, well-maintained gardens and grounds. Car parking is available within the grounds for visitors. The fees at this service range from £670 to £735.00 per week. Fees are based on individual assessed care needs and the room chosen. Residents pay separately for hairdressing, chiropody, opticians, personal toiletries and newspapers at cost. Please contact the home’s General Manager for more information. Eversfield DS0000064751.V365322.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 key unannounced inspection was conducted by Marion Weller, Regulatory Inspector, who was in Eversfield from 10:00a.m. until 5.35 pm. During that time the Inspector spoke with some residents, the General Manager and some members of staff. Parts of the home and some records were inspected and care practices observed. Additional information to inform the inspection report was taken from the annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is the home’s self assessment that focuses on how well outcomes are being met for people using the service. It also gives some numerical information about the service. A number of survey forms were received prior to the inspection. Residents, their relatives and health care professionals largely responded that they liked the home and thought good standards of care were being offered there. Statements made during the site visit included: “ This place is so perfect, I am so very happy here” “ I am very satisfied with the care, consideration and support that I receive” And “ Leaving my other home was a dreadful wrench, but I am now settled and happy here and it has proved to be beneficial in many ways” The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at Evesfield prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. The General Manager and the staff gave their full co-operation and help throughout the inspection. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Assessment documentation is in place to ensure the individual needs of residents are clearly identified before they move in. This ensures peoples needs can be met by the home. Records show that residents’ care plans are now being reviewed at least once a month; they are being updated to reflect the individuals changing needs and any current objectives for health and personal care. Evidence further shows that changes are clearly being actioned to the benefit of the people receiving care. Assessments of any risks to residents are being carried out, including the risks associated with the use of electrical equipment such as electrically operated beds. This ensures their health and welfare is better protected. Residents meetings are now taking place and people living in the home are regularly being consulted about their social interests and ideas for menu planning. Arrangements are made to enable individuals to take part in local, Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 7 social and community activities, which ensures the lifestyle experienced in the home matches peoples expectations and preferences. To ensure that the home is managed and conducted to promote and make proper provision for the health and welfare of people living there, all windows where there was previously a risk of someone falling out, have been restricted to eliminate any potential for harm. The home’s fire doors, designed to close automatically to protect residents in a fire emergency, are now being monitored by senior staff and the practice of wedging them open has ceased. The manager has firm plans to publish and supply to residents and other stakeholders, including the CSCI, the results of any surveys regarding the quality of the service provided at Eversfield. 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. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 6. Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their needs will be properly assessed prior to them making a firm decision to move in. They further benefit from being able to visit the home prior to admission. EVIDENCE: The home has an admissions policy in place. The home’s AQAA records that this is dated March 2001. The new manager stated her firm intention to review and update each of the home’s policy documents in line with changing legislation and good practice demands. The manager described how a pre-admission assessment is made of each prospective resident to ensure the home can meet his or her needs. The written assessment covers all aspects of the individual’s health, personal care, emotional support and social and cultural needs. Three pre admission assessments were inspected on this site visit. The manager is aware that Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 10 residents admitted some years ago do not have pre admission assessments on record however; the home’s current practice clearly meets the demands of Regulation and the National Minimum Standards. Both the manager and her deputy carry out pre admission assessments. They would, if practical, visit the prospective resident to ensure the initial information they had been provided with remained current and accurate. Records show that prospective residents, their families, advocates, and relevant health care professionals are involved in the assessment process. Specialist advice is sought from external sources where required. The manager stated that residents are admitted on a month’s trial basis. Residents said they or their families had been able to visit Eversfield and meet the staff before moving in and were encouraged to stay for lunch or supper. Respite care can be provided if a room is available and the service can meet the resident’s needs. There is no specific accommodation for short-term care; the resident is free to join in with daily life in the home. Eversfield does not provide Intermediate Care. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10. Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s health and social care needs are clearly set out in individual plan of care ensuring their needs will be met. They are largely protected by the home’s policies and procedures regarding medication administration. They can be confident that where minor shortfalls exist the home will review its arrangements and facilities to secure their safety and protection. The privacy and dignity of service users is considered important and their independence is promoted. EVIDENCE: All residents have a care plan. Three care plans were looked at in detail. The home has a computerised care planning system called ‘Saturn’. Staff are trained during induction to use the system to residents benefit. Care plans are also printed out regularly and retained in A4 files to ensure they are available to the person to whom they relate and for audit/ inspection and review purposes. The care plans seen were based on a full needs assessment and set Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 12 out in detail the action required to ensure all aspects of the health, personal and social care needs of the individual were met. They gave clear direction and guidance for staff to follow. It was evident that all care plans were being reviewed monthly in line with a requirement made at the last inspection. It would better evidence the home’s good practice if each service user file evidenced a clear list of care plan review dates, the elements reviewed and any changes made to the main plan. Each resident or their representative had signed the care plan to illustrate their involvement in its compilation and agreement to it. Where individuals lacked capacity to understand the full content of their care plan, it was discussed that the home should record the reasons why the individual is not signing the care plan. Staff were observed during the site visit to be regularly referring to peoples care plans and updating content using Saturn. Staff spoken with were aware of the content of residents care plans and the need to review them regularly. Resident’s daily records were being maintained. Most entries were fairly detailed and largely reflected care plan demands. Some service user files would benefit from a timelier archive and this aspect of organisation was discussed with the manager. The health needs of individuals were identified and their preferences for support were documented. Some individuals had an assessment completed identifying any risk of developing pressure sores. Preventative equipment had been provided where it was necessary. Nutritional screening was conducted and moving and handling assessments completed, identifying any equipment that was required. In line with a requirement issued at the last inspection, a range of other risk assessments were completed, these included the risks associated with the use of electrical equipment such as electrically operated beds. Care plans indicated that a range of health care professionals, including a General Practitioner, chiropodist and a district nurse visits the home regularly to support residents. Records were being maintained of all health care consultations and interventions received by residents. The arrangements for the safe receipt and disposal of medication were largely robust. The home has a policy and procedure in regard to the administration of medicines in place, with a last review date of November 2007. The home uses a monitored dosage system provided by a local pharmacy. Medicine Administration Record sheets (MAR’s) were evidenced for recording medicines given to service users. The MAR records for residents were being accurately maintained except where hand written entries had been made. The person making the entry had not signed it, neither was the entry signed by a second person to confirm accuracy of transcription. This practice potentially places service users at risk of a medication error/ wrong medication being given. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 13 The supplying pharmacy visits the home annually to carry out an audit and to give good practice advice. The last report was viewed. There were some recommendations for improvements to practice. Residents who wished to self medicate and take responsibility for their medication had a risk assessment in place. The assessment process could be further improved by also assessing if the individual knew what would happen if they did not take their medicine as prescribed. The results of self medication assessments should be written and retained in the service users file for review should circumstances change. Prescribed topical and oral medicine preparations were observed in some bedrooms, clearly on view and not locked away when not in use, as good practice demands. The risk assessments for those individuals electing to self medicate must be revisited if they fail to understand the importance of safe storage, to ensure everyone’s safety and welfare in the home. Staff who are designated medication administrators receive training regarding the safe administration of medication to residents. Guidance documents were also available in the medication storage room to further direct staff in good practice. Some documents now need to be updated to ensure information supplied to staff is current. For instance, The Royal Pharmaceutical Society guidance document was not their most recent published copy, entitled ‘The Handling of Medicines in Social Care, neither was the home’s copy of the BNF current. The home has a sound CD cupboard and maintains a CD Register. The home was able to evidence medication disposal records, which were robust. Minor shortfalls detailed above were discussed with the manager. The inspector is confident the home will quickly review its arrangements and facilities to secure residents safety and protection. Observation evidenced staff were considerate of the age and dignity of residents and were observed to treat them with courtesy and respect. Residents spoke highly of some staff. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Service users experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have a relaxed, comfortable lifestyle with opportunities to occupy themselves with a range of interests. They are also offered a nutritious, well balanced diet and their views are considered when menus are planned. EVIDENCE: Eversfied is a place where residents can live a life as much as possible to their own choosing and where they can welcome friends and family. Whilst there are the expected routines of a well managed service and residents understand this, as far as practicable, residents can make their own choices about their day. Residents said that, within reason, they could get up and go to bed when they chose. Some people are able to go out and visit local shops or other attractions as they still drive and maintain their own transport. The home has a mini bus for the less able, which is used to transport people to local social and community events. The new manager spoke of her intention to use the mini bus more regularly for outings over the coming year. Meals are at regular set times which residents said they didn’t mind, although at breakfast Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 15 time residents can elect to have a breakfast tray brought to their room. One resident said, “Very caring home – specially in recognising peoples individuality” The home normally employs a full time social events coordinator, although on the day of the site visit the post was vacant. The manager has however recruited and arrangements are in place for the new events coordinator to start in a matter of weeks. It is normal practice for the coordinator to provide a full programme of events. Recently recorded events included, exercise to music, flower arranging, church services, outside entertainment, film shows, classical music events, audio book club, ‘read around’, and pamper sessions and drinks parties. The home also holds monthly themed parties celebrating events such as St. George’s day, Burns Night, Valentines Day etc as well as offering themed meals from around the world. The manager records in her AQAA that over the next 12 months she is intending to recruit an additional part time social events coordinator to support the full time staff member. A well-stocked library room is available to people living in the home. The mobile library also visits every three months to provide a regular exchange of books. Newspapers of a resident’s choice are ordered and distributed and a hairdressing service is available every week. Visitors to the home are made very welcome and a small sitting room can be used to entertain visitors or for residents to invite family or friends in for lunch or dinner. Some residents also spoke of inviting friends into the home for card games. A kitchen is provided on each floor of the home to enable residents or their visitors to make their own refreshments if preferred. Residents are encouraged to personalise their rooms with their own possessions if they wish. Most residents have brought special items of furniture and plenty of personal effects with them. As rooms are differently shaped and sized, this leads to very individual environments. Resident’s meals are served in a spacious, well-equipped and attractive dining room. A weekly menu is on display for information and daily menus are provided on each table. Tables are nicely laid up and there are a well-balanced, nutritious variety of meals on offer, including a choice of two main meals each day. Staff ask residents each day what they would like to order for the following day. Other options, including salads, omelettes and filled jacket potatoes are also available if the main menu is not to the individuals liking. The home has its own team of catering staff. The home’s Chef advised that specialist diets could be catered for and currently the home was catering for diabetic residents. A vegetarian option is offered each day for those who prefer it. Residents spoke of being involved with a recent review of the home’s seasonal menus. A recent complaint dealt with meat that was considered to Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 16 be tough. This concern was investigated and it was clear from the actions taken as a result that peoples opinions are taken seriously and the home will go to some trouble to resolve issues to everyone’s satisfaction. Eversfield DS0000064751.V365322.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 18 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service People who use the service can be confident that their concerns and complaints are taken seriously and acted upon. They are also systems and procedures in place to protect them from the risks of abuse. EVIDENCE: The home has a robust complaints procedure, which is available within the statement of purpose. A CD version of the complaints procedure has also been made available to people this year. The home keeps a record of all complaints received by them. The home’s complaints register was inspected and it was clear that complaints and minor concerns are taken seriously, investigated fully and recommendations made as a result, implemented immediately. Residents said they felt confident that they would be listened to and any necessary action would be taken if they were concerned. The managers AQAA records the receipt of two formal complaints in the last year. The Commission has not received any complaints about the home in that time. There are procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The staff induction and NVQ training have elements of adult safeguarding training and there has Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 18 been POVA training for staff. Some staff are yet to be trained. The new manager has formulated a staff training programme and stated her intention to make this a priority. Dates for the next adult protection training course for staff is arranged for 18th August 2008. Staff spoken with had a largely sound understanding of adult abuse and safeguarding/protection procedures. The Manager stated any allegation of abuse would be referred to the concerned agencies without delay. There have not been any alerts in the last twelve months in relation to this home. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 19 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 26 Service users experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service People benefit from a clean, nicely furnished, well equipped and well maintained home with attractive décor and have easy access to pleasant grounds. EVIDENCE: Evesfield is a well designed, attractive and well-maintained home, offering all individual bedrooms with en suite facilities for residents. Each bedroom has a defined day/ night space. There are various sitting rooms and quiet areas for residents use. There is a fully stocked library and a very pleasant conservatory overlooking the grounds at the back of the home. The reception area is spacious and pleasant for people to sit in and enjoy the comings and goings of a busy home. For those arriving, a part time receptionist is employed to offer assistance. Hot coffee is available in reception for visitors to enjoy while they wait to be attended to or residents are told of their visitor’s arrival. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 20 The layout and use of the communal areas around the house are regularly reviewed to ensure that they meet the needs and capabilities of residents. The home is very well presented, clean, tidy and with no unpleasant odours. The garden was equally well-maintained and provided excellent views - easily accessible, well used and enjoyed by the people living there. The manager states they have a supportive estates department and a planned preventative maintenance programme is in place. High standards of housekeeping and laundry services were evidenced. All residents are offered keys to their own rooms, although information as to the retention of keys held by residents is not being recorded on care plans. All residents have access to at least one lockable draw in their bedrooms. The home is well provided with equipment for direct care, cleaning and maintenance. Toilets and bathrooms evidenced paper towels and liquid soap to prevent the spread of infection. Staff were very well presented in uniforms provided by the home. Staff advised that personal protective equipment, including aprons and gloves are made available to them and used to aid infection control measures. Records seen indicated that seven staff have undertaken infection control training. The new manager has a training programme in place; a further staff-training course for infection control is arranged for 13th August 2008. To ensure service quality is maintained, the manager records in her AQAA that quarterly hotel service audits are undertaken and the environment is included in annual satisfaction surveys. People living at Eversfield clearly love the home and many positive comments from residents were received during the site visit. The new manager discussed her plans for the next 12 months in relation to the environment. This included replacing the carpet in the dining room and the provision of new linen and a complete refurbishment of the décor. There are also plans to reorganise and decorate the reception area and to redecorate resident’s bedrooms as and when they become available or there is an identified need. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet the needs of residents and recruitment checks are being carried out to protect them from any potential for harm. The service clearly recognises the importance of staff accessing induction and mandatory training and there have been improvements. Gaps in current arrangements and practices need to be addressed to ensure that staff employed are suitably developed and supported in their role to provide highly effective person centred care in line with the aims of the home and the changing needs of residents. EVIDENCE: It remains clear that residents are supported by a stable team of staff, some of whom have worked at the home for a number of years. They are deployed in suitable numbers to meet resident’s needs. Residents spoke highly of staff that they know well and like. Information recorded in the Home’s AQAA confirmed that 15 care staff have achieved a National Vocational Qualification (NVQ) to level 2. A further 7 are currently working towards the qualification. The home therefore meets the recommended standard of 50 of staff trained to this level. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 22 Three staff files were inspected on this site visit. All the required recruitment checks had been carried out, including obtaining two references for each person and a Criminal Records Bureau (CRB) disclosure and POVA first check. The manager advised that the home’s system of induction meets the Skills for Care common induction standards framework. Skills for Care induction and foundation standards were updated in October 2005. The old standards were withdrawn from 2006 and have since been replaced. As staff advised that the same video system of induction is still being carried out in the home, the new manager needs to assure herself that content meets the required standard and the demands of regulation. Using the home’s system, staff watches a video relating to a specific area of their work, such as the role of the care worker and fire safety and then completes a questionnaire to check their understanding of the information in the video. From the limited induction records seen, induction of new staff needs to be further improved. Topics covered must be clearly recorded in each employees staff file and the trainer and trainee should sign the record as evidence of achievement. Induction records must be maintained by the home. A staff-training matrix was seen. It was evident that there have been improvements since the last inspection and more training is being planned. A number of staff however still need to receive some aspects of mandatory and other training appropriate to their role. The role undertaken by the staff member should also be recorded on the training matrix for audit purposes and to give the manager a clear overview of staffs training needs. This must include ancillary and support staff. The new manager is aware of gaps in staff training and development and has formulated an interim training programme. Training events booked until the end of August 2008 currently cover Mental Capacity Act training, Infection Control, Adult Protection, Health and Safety and First Aid. The new manager stated her intention to fully resolve the issue of staff training and development to ensure the home is able to evidence staff are suitably trained and competent to do their jobs. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 23 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 36 38 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a service that is run in their best interests by a manager and staff who are committed to providing a good quality of life for older people. Where shortfalls exist there are firm plans for improvement and the clear potential for improvements to be sustained. EVIDENCE: The Registered Provider appointed a new manager for Eversfield in February 2008. The manager intends to make application to become the home’s Registered Manager and successfully complete The CSCI fit person process. The manager explained that she has 24 years of elderly care experience and 18 years of management experience. She is a Registered General Nurse and Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 24 has successfully completed the Registered Managers Award. There are clear lines of accountability within the home and with external management. A Head of Care and an Administrator support the manager. The manager is aware of current shortfalls in relation to staff induction, mandatory training and formal staff supervision, together with some outstanding issues of Health and Safety. She is relatively new to post but explained her initial plans and clearly evidenced that work had already started to address these areas. For example, COSHH risk assessments, currently not in place, were being complied on the day of the inspection by an external advisor. The manager records in the home’s AQAA that her intentions are “To improve our service wherever possible for the benefit of the residents. To bring Eversfield up to the status of a very high quality care home. This will be done by training of our staff and regular meetings with our residents” The service has recently undertaken their annual quality assurance exercise. The manager explained that the objective is to obtain the views and opinions of residents and other stakeholders as to quality of the service being provided to people at Eversfield. The manager is in the process of collating survey responses. The results will be published and made available to current and prospective users and other stakeholders, including the CSCI, as Regulation demands. Visits to the home by a representative of the organisation under regulation 26 are carried out and recorded monthly. People living in the home advised that regular residents meetings are now being held with minutes available for reference. Residents meetings had previously lapsed and were a cause of some concern. At the last inspection a number of residents raised the need to discuss their views with the manager, particularly in relation to food and daily activities. Re-establishing such events allows people to openly air their opinions and take part in decision making within the home. The recommendation made in the last inspection report in realtion to resdients meetings has now been addressed. The finances of residents are well controlled and safeguarded. Money is held for safekeeping for a number of people. The home’ administrator and senior staff are the only individuals with access to funds and two signatures are recorded for each transaction. Residents are provided with a lockable facility in their bedrooms, in which to store valuables. Since the last inspection a number of windows on the upper floors of the home have been fitted with restrictors to prevent them opening fully. This action prevents and safeguards anyone from falling. The home’s fire doors, designed to close automatically to protect residents in a fire emergency, are now being monitored by senior staff and the practice of wedging them open has ceased. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 25 From information supplied in the AQAA, it is clear that the required maintenance and checks on systems and equipment in the home are carried out to the required frequency, to promote the safety and welfare of all who live and work at the home. Health and Safety at Work posters were displayed in a number of locations in the home and the home’s insurance policy was displayed as required, in the entrance hall. Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 26 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18 1 (c) (i) (2) Requirement The registered person(s) must ensure that supervision arrangements are put into practice. In that: • Staff must receive formal supervision at least 6 times a year. • Supervision must cover all aspects of practice, the home’s philosophy and the supervisee’s career and development needs. Supervisors must receive appropriate training in delivering supervision, which is appropriate to their role. A written record should be kept to evidence supervision is taking place Timescale for action 01/12/08 • • Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 28 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 OP9 Good Practice Recommendations It is strongly recommended that the registered person(s) fulfil the stated intention of reviewing the medication administration practices in the home in line with good practice advice to secure residents safety and protection. It is strongly recommended that the manager fulfils the stated intention of formulating a robust rolling staff training programme that ensures all staff receives training appropriate to their role. Staff induction processes, procedures and the organisation of induction records should be reviewed in light of recent changes and to ensure staff are being inducted properly. 2. OP30 3. OP30 Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Eversfield DS0000064751.V365322.R01.S.doc Version 5.2 Page 30 - 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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