Annual service review Name of Service:

Evendine House

The quality rating for this care home is:

three star excellent service

The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.  

Has this annual service review changed our opinion of the service?

No

 

You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector:

Date of this annual service review:

Sandra Bromige

0

Annual Service Review

9

0

6

2

0

0

9

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Information about the service Address of service:

Evendine Lane Colwall Malvern Worcestershire WR13 6DT

Telephone number:

01684540225

Fax number:

F/P01684541963

Email address: Provider web address:  

Name of registered provider(s):

S B Residential Care Limited

Conditions of registration: Category(ies) :

Number of places (if applicable): Under 65 Over 65

dementia

0

6

mental disorder, excluding learning disability or dementia

0

6

old age, not falling within any other category

0

20

physical disability

0

2

Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Evendine is located on the edge of Colwall, a village located in a rural area between Malvern and Ledbury. The home is set in well maintained gardens that are easily accessible to the residents. There are extensive views of the Malvern Hills and surrounding countryside. There are 20 registered places. All these places are registered for people over 65 years of age who have care needs arising from the usual ageing process. Six of the places may be used for people over 65 years of age who have care needs arising from a mental disorder. A further six of the 20 places may be used to accommodate people over 65 years of age who have care needs arising from Annual Service Review

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dementia. The accommodation is on two floors with access by a chair lift to the first floor. There are 19 bedrooms, one of which is for two people who wish to live together. All potential or new residents receive an information pack that describes the service they can expect to receive. Brochures are also displayed in the main entrance hall at the home. Up to date information relating to the fees charged for the service is available on request from the home.

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Service update since the last key inspection or annual service review: What did we do for this annual service review? The last key unannounced inspection was carried out on the 21/05/08 and the judgment was the service was providing a three star excellent service. We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications' and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. What has this told us about the service? Evendine House returned the annual quality assurance assessment (AQAA) before the date they had to send it to us. This was very well completed, clear and comprehensive. The AQAA and the last key inspection report showed that the service obtain comprehensive information about peoples needs and expectations before they agree to admit. This helps the service decide if the potential admission is likely to be a success for everyone. The AQAA tells us "our assessment process covers 36/37 aspects of care to ensure a comprehensive care plan can be produced prior to admission incorporating all care needs, cultural, religious and social care preferences". The AQAA told us how the service is operating and the improvements they have made and wish to make. We read the AQAA and our judgment is that the service is still providing a three star excellent service. The key unannounced inspection which was carried out on the 21/05/08 also formed a judgment that the service was providing a three star excellent service. To ensure equality and diversity is addressed the information within the AQAA told us "the home operates an equal opportunities policy and we strive to ensure" that race, gender equality, disability, sexual orientation, age, religion and belief "are respected, promoted and incorporated in line with the home's ethos". "We promote diversity and would welcome clients of any race and incorporate and promote their different requirements to maintain their identity and beliefs. "We ensure that those residents who suffer from a disability of any kind are not discriminated against and take steps to

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ensure they participate in daily life to the full". The AQAA contained numerical data which told us they provide a service for older people who have a range of needs such as general frailty due to old age, mental disorder, dementia and physical disability. The service currently employ a multi-cultural team of female care staff. We received four surveys from people who use the service, three relatives, carers or advocates, one health professional and five staff members. We did not receive any written comments from people using the service or their relatives. The response to the questions in the surveys were all very positive. The response from the health professional in the survey when we asked what the service does well stated: "General rest home care". The response from the staff in the surveys when we asked what the service does well were: "Relaxed, welcoming atmosphere. Residents are encouraged to voice their opinions and concerns". "Offers an excellent quality of care for the residents, which allows them to regain and build on their confidence. Safe, clean environment." "Rarely use agency staff, so service users get good continuity of care staff they know. Act upon any problem a service user may have, all staff report back to the management team, who then deals with the situations when they arise". "As I have worked here for 5 years I think that shows that it is a good place to be, there is not a fast turnover of staff so they are more involved with how things are run, a good deal of trust and being allowed to do your job." "Evendine House is a very nice place to work, it has very good staff. All external services that come into the home always comment and say they would like to move into the home when residential care is needed". "Going by visitors comments Evendine is doing it right, a nice home to live in, caring happy staff who share any problems arising from the welfare of residents". We also asked staff what the home could do better and they said: "Take the residents on more outings. Do more activities that all residents would enjoy joining in with". "More activities that residents can join in with". "Have more staff meetings". "Staff meetings would help us, as we all do different shifts and things do change from time to time". "It would benefit us to have more staff meetings". Information in the last key inspection report dated 21/05/08 also tells us that the people using the service were pleased with the standard of care they receive. The AQAA told us the service has received three complaints in the last 12 months and these were upheld. No safeguarding referrals have been made since the last key unannounced inspection. We have received one complaint about the service since the last key inspection, this was referred to the Provider to investigate. The complaint was not upheld. We have not received any notifications from the service since the last key inspection in May 2008. There have been no changes to the management structure or registration details since the last key inspection which was undertaken on 21/05/08. The AQAA tells us about the policies and procedures the service has in place and when they were last reviewed. There are a number of policies which have not been reviewed Annual Service Review

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for over two years, for example disclosure of abuse and bad practice, equal opportunities, diversity and anti-oppressive practice, food safety and nutrition, health and safety, management of service users money, safeguarding adults and the prevention of abuse, physical intervention, restraint. These and other policies and procedures need to be reviewed to ensure they reflect current legislation and practice. What are we going to do as a result of this annual service review? There will be no change to the inspection plan and we will do a key inspection by 21/5/2011. However, we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service.

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Reader Information Document Purpose:

Annual service review

Author:

CQC

Audience:

General Public

Further copies from:

0870 240 7535 (national contact centre)

Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website.

Helpline: Telephone: 03000 616161 Email: [email protected] Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

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