Inspection on 14/03/08 for Devereux House

This is the latest available inspection report for this service, carried out on 14th March 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Devereux House 18/10/05

Devereux House 31/05/05

Devereux House 21/12/04

Devereux House 16/06/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Devereux House 69 Albert Road Farnborough Hampshire GU14 6SL Lead Inspector Craig Willis Unannounced Inspection 14th March 2008 9:50 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 Devereux House DS0000012109.V359295.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. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Devereux House Address 69 Albert Road Farnborough Hampshire GU14 6SL 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) 01252 512 967 01252 541935 devereux-house@supanet.com Farnborough and Cove War Memorial Hospital Trust Evelyn Mary Smith Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only (PC) - to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Physical Disability (PD) The maximum number of service users to be accommodated is 16. Date of last inspection 31st October 2006 Brief Description of the Service: Devereux House is a care home providing care and accommodation for 16 older people. The home is owned and managed by the Farnborough and Cove War Memorial Hospital Trust. Devereux House is located in a quiet residential area near the centre of Farnborough, within easy access of all the local amenities. Accommodation is provided on the first floor with the ground floor being used as a day centre. The home has private enclosed gardens that are accessible to people. Fees at the home range from £459 to £570 per week. Devereux House DS0000012109.V359295.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 star. This means the people who use this service experience good quality outcomes. The evidence used to write this report was gained from a review of the information the provider sent to us since the last visit and the previous inspection report. This information included incident reports and an annual quality assurance assessment. A site visit to the home was made on 14 March 2008. During the visit we spoke with six people who live in the home, the manager and staff on duty. We received surveys from five people who live in the home, four relatives, three health professionals and four members of staff. The communal areas of the building were viewed and documents relating to the running of the home were inspected during the visit. What the service does well: There are good systems to assess people’s needs before they move into the home. This helps to assure people that the home will be able to meet their needs. People’s needs are set out in good care plans, which give staff the information they need to provide the right care. There are good systems in place to safely manage people’s medication. The home provides a good range of activities to meet people’s different needs and visitors are made to feel welcome. There are good systems to deal with complaints and respond to allegations of abuse. This gives people confidence that any complaints they make will be taken seriously and investigated. The home is well maintained and provides a homely, comfortable and safe environment that meets people’s different needs. Staff are well trained and there are enough of them on each shift to meet people’s needs. The home is well managed and staff are supported to do their jobs effectively. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 7 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 Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 8 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): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to assess people’s needs before they move into the home. This helps to assure people that the home will be able to meet their needs. EVIDENCE: The manager reported in the annual quality assurance assessment for us that people are not admitted to the home before they have had a full needs assessment and she is confident that their needs can be met by the capabilities of the staff. We looked at the files of four people who live in the home during the visit. Each person had an assessment of their needs that was completed before they moved into the home. This assessment included people’s mobility, personal care, health care, social, spiritual and cultural needs. During the visit a member of the public came into the home to discuss whether it would be a suitable place for a friend. The manager clearly explained what the home Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 9 offered and the process for assessing the persons needs to ensure the home would be able to meet them. Five people who live in the home completed a survey for us and all said they received enough information about the home before they moved in so they could decide whether it was the right place for them. The home does not provide intermediate care, therefore standard six is not applicable. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 10 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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are set out in good care plans, which give staff the information they need to provide the right care. There are good systems in place to safely manage people’s medication. EVIDENCE: The files of four people who live in the home were inspected during the visit and all contained a care plan. The care plans had been developed from the initial needs assessments and set out how these needs should be met. The plans include an assessment of any risks identified, for example concerning people’s mobility or spending time alone in the garden. The risk assessments contain action that should be taken to minimise the risks identified. All of the care plans seen had been reviewed regularly, with amendments made where people’s needs had changed. Staff spoken with said they found the information in the assessments and care plans to be accurate. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 11 Records inspected demonstrated that people have access to a range of health services, including GP, district nurse, chiropodist, physiotherapist and hospital outpatient services. Records of visits were kept in people’s file and included any advice from the practitioner. People spoken with said they were able to see their doctor when they need to. Five people who live in the home completed a survey for us; four said they always receive the medical support they need and one did not answer the question but added, “they call the doctor but he doesn’t always come”. Medication is administered by staff who have completed training. Medication held by the home is stored in a locked trolley and most tablets are provided in blister packs. The medication administration record for the current month was inspected and was fully completed. No one at the home is currently prescribed any controlled drugs, although there are systems in place should they be necessary, with a controlled drugs cupboard and register. Two GPs and a podiatrist completed a survey for us and reported that people’s health care needs are always or usually met by the home. No examples were given where people’s needs were not met. People spoken with said staff treated them very well. During the visit staff were observed responding to people in a manner that maintained their privacy and dignity, for example waiting for a reply before entering a bedroom and taking a portable phone to someone’s bedroom so they could receive a call in private. All five people who completed a survey for us said the staff listen to them and act on what they say, with one person adding, “they are very quick to provide any aid or assistance I require”. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 12 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): Standards 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 home provides a good range of activities to meet people’s different needs and provides a choice of food that most people like. People are supported to keep in contact with their family and friends and visitors are made to feel welcome. EVIDENCE: Details of people’s interests and hobbies are gained as part of the initial assessment and included in people’s care plans. The home organises a range of activities including music for health, games, crafts, quizzes, light exercises and outings. The home has a range of books and games that people can borrow and the mobile library visits. People spoken with said they like the activities that are organised. Five people who live in the home completed a survey for us. All said there are activities organised that they could take part in, although two said they would like more to be organised. The manager reported in the quality assurance assessment that she is planning to provide more activities over the next year. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy, with visitors able to come to the home at any time. Four relatives completed a survey for us. All said they were kept up to date with important issues affecting their relative. People spoken with said they were able to decide how they spent their time and what activities they took part in. People are able to practise their religion, with spiritual leaders made welcome in the home, for example so that people can receive communion. Arrangements are also made for people to travel to places of worship if they wish. A requirement was made at the last inspection that the home must ensure people are involved in the planning of menus for the home and that the home operates a quality assurance system so that service users are consulted regularly on the meals they receive and that their views are recorded, taken into account and where service users have expressed dissatisfaction, this must be acted upon. The manager reported that food is discussed at residents’ meetings and suggestions for different meals reported to the cook. A new cook has been employed since the last inspection and more meals are now being freshly prepared and there is a choice of two meals. People spoken with said the food was generally good and confirmed that alternatives were available if they wanted, for example, one person followed a vegetarian diet. Five people completed a survey for us; one said they always like the meals at the home, two said they usually did and two said they sometimes did. The mealtime was observed and appeared a relaxed social occasion. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems to deal with complaints and respond to allegations of abuse. This gives people confidence that any complaints they make will be taken seriously and responded to. EVIDENCE: The home has a complaints procedure, which is included in the service users’ guide and displayed in the home. People spoken with during the visit said they were confident any complaints they made would be taken seriously and investigated. Five people who live in the home completed a survey for us and all said they know who to talk to if they are not happy and how to make a complaint. All four relatives who completed a survey for us said they know how to make a complaint and those that had raised any concerns felt the home had responded appropriately. No complaints have been received by the home or us in the last year. The home has procedures in place to respond to allegations of abuse and staff have received training in the safeguarding adults procedures. Staff spoken with demonstrated a good understanding of different types of abuse, signs that someone may be being abused and what to do if abuse is witnessed, reported or suspected. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 15 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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a homely, comfortable and safe environment that meets people’s different needs. EVIDENCE: All of the home’s communal areas were inspected during the visit. All areas were clean and well maintained. People spoken with said that the home was always well maintained and kept clean. People also said their bedrooms were comfortable and had all that they needed in them. Staff reported that maintenance is completed quickly when required. The manager reported that there are plans to redecorate the communal areas in the next year. Since the last inspection a new shower room has been built, giving people the option of a bath or shower. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 16 The home has a separate laundry room located in the day centre section of the building, with machines capable of washing soiled clothes if necessary. There are infection control procedures in place and hand washing facilities in the laundry room, kitchen, toilets and bathrooms. Staff are provided with protective clothing, for example gloves and aprons, and were seen using them during the visit. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 17 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): Standards 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. Staff are well trained and there are enough of them on each shift to meet people’s needs. There are systems for protecting people by checking staff before they start work, however, they are not consistently followed. EVIDENCE: The home has at least three care staff on each day shift, with one night care staff and one person asleep in the home and on-call overnight. People spoken with said they thought there were enough staff to meet their needs, adding that staff come quickly if they use their call bell. The five people who live in the home who completed a survey for us all said staff are always available when they need them. Staff spoken with said they thought there were sufficient staff on all shifts. Four staff members completed a survey for and all said there were either always or usually enough staff to meet people’s needs. The manager reported that all staff working in the home have had suitable preemployment checks. The records of one member of staff employed in the last year were inspected and contained confirmation that a Criminal Records Bureau disclosure had been obtained and confirmation that the person was not on the protection of vulnerable adults list as unsuitable to work in a care home. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 18 Two written references had been requested but only one had been obtained. The manager reported that this had been an oversight and action would be taken to chase up the missing reference. Staff spoken with said they had regular meetings with their supervisor, which they found helpful. Staff complete an induction programme when they start work. Seven of the sixteen permanent and bank care staff have completed the NVQ at level 2 or above and four are currently completing the award. The home has a training programme in place, with courses including first aid, fire safety, infection control, moving and handling, safeguarding adults, continence, challenging behaviour and medicine management. Staff spoken with said they thought the training was relevant to their role and gave them skills and knowledge to meet people’s needs. All four staff who completed a survey for us said they received training that was relevant to their role, helps them understand people’s diverse needs and keeps them up to date with new ways of working. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 19 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): Standards 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 home is well managed and staff are supported to do their job effectively. There are good systems to assess the quality of the service provided, plan improvements and to promote people’s health, safety and welfare EVIDENCE: The manager has been registered with us since May 2007 following an assessment of her skills and experience. She has completed the NVQ level 4 in care and is currently completing the registered manager’s award. During the visit the manager demonstrated her knowledge of the service and a commitment to ensure that she continues to update her skills and the service Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 20 improves where necessary. Staff spoken with said they receive very good support from the manager. A member of the Trust that runs the service visits each month to assess how the home is performing. Reports of these visits are made and sent to the manager. The reports contain a list of any actions that are required, including an assessment of whether previous requirements have been completed. In addition, an annual survey is completed of people who live in the home and their relatives. The results of the audits and surveys are used to make planned improvements to the home. The manager reported that they do not hold money or act as appointee for anyone who lives in the home. The manager reported in the annual quality assurance assessment that all equipment in the home is regularly serviced and checked to ensure it is safe. During the visit we sampled servicing records for the fire alarm, fire extinguishers and the gas system, which confirmed the manager’s report. Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 21 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 3 10 3 11 X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Devereux House DS0000012109.V359295.R01.S.doc Version 5.2 Page 23 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. 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