Inspection on 01/02/07 for Devenish House

This inspection was carried out on 1st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Devenish House 10/11/05

Devenish House 03/06/05

Devenish House 11/01/05

Devenish House 20/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Devenish House 49 Southgate Street Winchester Hampshire SO23 9EH Lead Inspector Pat Trim Unannounced Inspection 09:30 1 February 2007 st 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 Devenish House DS0000039639.V320757.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. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Devenish House Address 49 Southgate Street Winchester Hampshire SO23 9EH 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) 01962 842878 01962 868437 St John`s Winchester Charity Mrs Joanne Marie Croft Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21), Terminally ill over 65 years of age (21) of places Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2005 Brief Description of the Service: Devenish House is a residential care home with nursing for twenty-one residents over the age of sixty-five years. The home is a listed building that has been modernised internally to provide accommodation of a high standard on three floors. All residents are accommodated in single rooms with en-suite facilities. The home has a large conservatory used as the main lounge on the second floor, a dining room on the ground floor and small sitting areas are provided on each floor. Devenish House also has a small chapel/quiet room for use by residents, staff and visitors. There is a small courtyard/garden area with seating and residents are able to access the gardens of another home close by. The home is situated in the heart of Winchester, close to all local amenities. Devenish House is part of a range of integrated care for older people in Winchester, provided by a Christian organisation, the St Johns Winchester Charity. The current fees provided by the registered manager are from £327.00 to £421.00 per week. Items not covered by the fees include hairdressing, chiropody, toiletries and newspapers. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection carried out by one inspector in 5.5 hours. The key standards were assessed by case tracking 3 residents and talking with 5 people currently living in the home and a visitor. Time was also spent observing staff practice and the daily routines of the home. There was an opportunity to talk with 5 care staff, the manager and the deputy manager. Some time was spent reviewing a random selection of documentation and a partial tour of the premises was carried out. Prior to the visit a review of the home’s recent history was undertaken, including the previous reports. Information was also gathered from the preinspection questionnaire, which was completed by the home. The people living in the home had previously expressed their wish to be called residents. This term is therefore used throughout this report. What the service does well: The home provides a warm, friendly environment where the needs of the residents are central to the day-to-day running of the home. There is good interaction between staff and residents and routines are unhurried and relaxed. Residents said they felt they were extremely well cared for and that their rights were respected. Comments made included: • • • • ‘I had to go somewhere else till they had a vacancy here. It’s very goodthey are so kind, I am glad I was able to move’ ‘I was able to bring some of my things. They are going to make my room bigger and I will be able to bring more. They said I can’. ‘Matron came to see if everything was okay. They changed my mattress because I said it was too soft and I didn’t like it.’ ‘I’m able to choose what I do here – it’s an excellent home and I’ve tried a few’. There are systems in place to monitor how things are going and to constantly review outcomes for residents. They said they felt able to speak out about the service they receive and to contribute ideas to improve the way the home is run. Residents have the opportunity to join in a wide range of activities and time is planned for them to spend one to one time doing what they like as individuals as well as having group activities. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 6 The assessment completed before someone moves in is very detailed and gives the person the opportunity to discuss what help they need. This information is used to write a care plan that makes sure people get the help they need in the way they like it. • • • ‘They wash my back and my feet. I can do the rest myself’. They bring my tea at 6:30 a.m. Then I can get myself dressed, but I must have my tea first.’ ‘They make sure I have lots of water and cranberry juice at night because that’s when I need it’. 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. Devenish House DS0000039639.V320757.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 Devenish House DS0000039639.V320757.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): 3. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed pre admission assessments ensure that residents can be confident they will only be offered a place if their needs can be met. EVIDENCE: Residents spoken with during the inspection remembered the registered manager visiting them prior to admission. One had already experienced living in the home as a short stay and said this had helped her decide to move in on a permanent basis. Three residents, who had recently moved into the home, were case tracked. Their files contained information about the prospective resident’s needs from a variety of sources. Copies of care management assessments and nursing assessments were used to supplement the information obtained by the registered manager, and to identify whether nursing or residential care was required. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 9 Each resident had a comprehensive assessment of need, completed prior to their admission to the home, which identified abilities and needs in all aspects of their personal, social and health care. Assessments included information recorded in the resident’s own words about what they could do and the help they required, their daily routines and likes and dislikes. Assessment tools were used to identify any areas of concern, such as the condition of a resident’s skin. This information was used to identify whether any specialist equipment would be needed on admission, such as a specific mattress, and whether any health care referrals would be required. For example, one resident who was in hospital prior to admission had lost her dentures. The pre admission assessment identified she would need a dental appointment arranged as soon as possible to be fitted for a replacement set. Devenish House DS0000039639.V320757.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): 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. Residents are supported to receive personal care in the way they like it and can be confident their health care needs will be met. Very robust systems ensure medication is extremely well managed to keep residents safe. EVIDENCE: There was evidence that the care plan was developed by using the information obtained in the pre admission assessment. For example, one pre admission assessment identified that a resident was able to do a lot of her personal care, but required assistance with washing her back and feet. This information had been recorded in the care plan, staff spoken with could describe the support needed and the resident confirmed that this was the assistance she received. The residents spoken with did not remember being involved in the development of their care plan, but confirmed they received care in the way they liked it. This aspect of the care plan could be developed to find ways to involve residents more. Care plans were regularly reviewed, using monitoring tools and amended when required. For example, one assessment had originally identified the need to Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 11 use bed rails, as there was a possible risk the person might fall out of bed. This had been monitored for a few weeks on admission, using a risk assessment tool and eventually the care plan had been amended to record bed rails were not required. The deputy manager audited care plans on a regular basis to ensure they were being reviewed and amended as required. Risk assessments were used to enable residents to maintain their independence and to monitor health care needs. For example, risks of falls and poor mobility were identified in the pre admission assessment and care plans contained strategies to minimise the risks. One resident was identified as having poor mobility and some sight loss. Strategies included ensuring she had a walking aid at all times, that her room was kept clear of clutter and that all staff were aware of her sight problems. Another pre admission assessment identified the risk of urine infections. The care plan required staff to ensure the resident had a constant supply of drinks and the resident confirmed staff continually brought her drinks throughout the day and night. Monitoring tools are also used to identify changes in health care needs. For example, one resident was admitted with a small leg ulcer. There was continued monitoring of the action taken and the outcome to ensure appropriate treatment was given. Residents felt their health care needs were well met and that they were able to access a wide range of health care support. Daily records showed referrals to health care professionals and during the inspection staff were observed asking residents who felt unwell if they would like to see the doctor. The home offers palliative care. The registered manager said she was currently working with the primary health care trust to implement the Liverpool pathway, a strategy for providing end of life care. The home operates well-developed and efficient medication policies, procedures and practice guidance. All staff have access to the written information and understand their role and responsibilities. Quality assurance systems confirm that policy is put into practice. The deputy manager carries out an audit of all medication procedures and practices each month. Two staff members check and record all the medicines that come into the home. A system is also in place for the disposal of medicines and this requires to staff to check all medicines to be disposed of. Medication records seen had been completed appropriately. Records seen for medicines stored in the controlled medicines cupboard matched the stock held. Staff were observed giving out medication to one resident at a time and signing the record after each administration in accordance with practice guidance. The home had up to date information on the medicines used in the home. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 12 Procedures are in place for residents who wish to administer their own medicines. The resident’s GP confirms that the resident is able to safely administer their medication and a risk assessment is completed by a trained nurse. Any change in the ability of the resident to administer their medication is noted and acted upon. Residents are provided with a lockable storage space for medicines kept in their own room for self administration. Residents felt they were treated with respect and that staff gave personal care in a private and dignified way. They said staff always knocked at their doors before entering and this was observed happening throughout the day. Their preferred form of address is recorded on their care plan and residents confirmed staff used this when speaking with them. Post was seen being given unopened to residents, who then asked if they required help with reading it. The induction programme that every staff has to complete includes looking at core values, the ethos of the home and residents’ rights. Staff, describing giving personal care, said they felt it was important to ask what help someone wanted and to give care at the pace the resident was happy with. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 13 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. Residents are able to make choices about all aspects of their daily living. The activities they are offered provide mental stimulation doing things they enjoy. The food provided offers a balanced diet with choices that residents like. EVIDENCE: Residents said they felt able to make choices about all aspects of their daily living. One resident said a number of residents had decided supper should be a social occasion and had asked that it be taken in the conservatory. A group now met every evening for supper. Residents described their daily routines and there was evidence that they were able to make individual choices. For example, breakfast is served in residents’ bedrooms at about 8:30 a.m. but they choose their routine, with some liking to have a cup of tea, then get dressed before breakfast, whilst others liked to have breakfast later and then get dressed. Individual choices were respected. For example, one resident had asked if she could bring her own pillowslips and sheets so she felt more at home. She said the registered manager had encouraged her to bring anything she wanted. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 14 Another resident had brought a lot of her own furniture and ornaments. One resident said she had accepted the room offered on admission because she wanted to move in but found it was too small. She had been promised a larger one as soon as it became available. Residents chose whether to spend time in the communal areas or in their rooms and were seen moving freely around the home. Some said they liked to go down for lunch, returning to their rooms to rest during the afternoon. Staff were seen assisting those who required help to go to the communal areas and their own rooms. One resident had attended the organisation’s day centre prior to moving in. He still went and said he was pleased to be able to keep in touch with the friends he had made there. Care plans identified residents’ interests and a wide range of activities was offered. Information about activities and outings was displayed in a corridor, with photos of recent events. Residents felt there was a good range of activities offered which included visits from pupils of the local college, bingo, scrabble and a recent visit from international folk dancers. Those spoken with said the activities were offered, but there was no pressure to join in. The registered manager said the home employed an activities co-ordinator. In addition to organised activities, time was also spent giving one to one time with individual residents, talking, or helping write letters. Although the home is run by a Christian organisation, the registered manager said anyone could apply to live at Devenish House provided they accepted the ethos of the home. The Charity’s chaplain visits the home on a regular basis to give communion to those who wish to receive it. The home has a small chapel that may be used by anyone who wishes to spend time in quiet reflection. Residents said their visitors were made welcome and could visit the home at any time. One visitor commented on how welcome he was always made to feel. The main meal had a vegetarian option offered every day and the menu choice was displayed on a small board in the dining room. Residents spoken with did not know what the meal choice was for the day but said that if, when they went to the dining room, they did not like what was offered, they would be able to have an alternative. One resident said the previous day the main meal had been curry and she had been able to have an omelette instead. The menu plans showed a varied and balanced diet was offered to residents at all times. The home had a good supply of fresh fruit and vegetables. The home employs cooks and kitchen assistants to provide the meals. Care plans identify dietary requirements relating to health care or cultural needs. For Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 15 example, whether someone had diet-controlled diabetes or does not eat meat. Meals that are available that meet these needs. Residents confirmed they were frequently offered drinks throughout the day and had jugs of water or squash in their rooms at all times. Snacks were available at any time. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 16 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. Residents have the information they need to enable them to make complaints and be confident they will be informed of the outcome of any investigation. A robust procedure and staff training ensure residents are protected against abuse. EVIDENCE: Residents spoken with said they had not made any formal complaints but were confident if they needed to any issues would be addressed. Informal complaints were swiftly resolved. One resident said she had not liked the mattress on her bed when she moved in. She told staff and the mattress was changed immediately. Another resident said when she moved in, her drinks had not been hot enough. When she reported this staff changed their practice so that her drinks were always really hot now. Copies of the complaints procedure were given to residents on admission and the service user’s guide contained a summary of the complaints procedure. The annual plan for the home included a decision that residents should have a laminated copy to keep in their rooms and this was being done. The commission had received no complaints since the last inspection. The registered manager had a complaints log, which was used to record any complaints received, actions taken and outcomes. The record showed that any complaints received had been dealt with in accordance with the home’s complaints procedure. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 17 The home had a policy and procedure for the protection of vulnerable adults, which was regularly reviewed. Records showed that staff received training on working with adult protection. Five staff on duty at the time of the inspection had all had adult protection training and were able to describe what action they should take if they witnessed any abuse. The registered manager had experience of working with the adult protection procedure. Devenish House DS0000039639.V320757.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to live in well-maintained environment that is comfortable, clean and safe and that they like. EVIDENCE: Residents said they liked the environment and felt it was able to meet their needs. They said they were encouraged to personalise their rooms. Some bedrooms are too small to be used for residents who require nursing. The registered manager said these are kept for those who require residential care only. The registered manager said there was a continuing programme of renovation and alteration to improve the environment. Recent alterations had been completed to widen corridors and make them more accessible to residents who needed to use a wheelchair. The registered manager said there were plans to continue improving access and to add a third assisted bath. It was also hoped that plans to enlarge several of the bedrooms would be approved. Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 19 The home is kept very clean and sweet smelling. Cleaning staff are employed and said they clean every bedroom every day. Residents said they felt the home was kept to a high standard and that domestic staff worked hard, cleaning every day. The home has systems in place to manage the risk of infection. The laundry is located in the basement, away from food preparation areas. Washing machines have programmes that are suitable for disinfecting soiled linen. Staff have access to disposable gloves and aprons and were seen using them when required. There are two sluices. Staff records showed they have training on infection control. There are policies and procedures that staff may refer to for guidance. Devenish House DS0000039639.V320757.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. Residents are supported by well-trained staff in sufficient numbers to meet their needs. A robust employment procedure ensures residents are protected. EVIDENCE: Residents said staff were knowledgeable about their individual needs and responded promptly to requests for help. The registered manager said staffing was arranged to provide flexible cover that met the needs of residents. Time was allocated so that shifts overlapped enabling staff to share information on a daily basis. Shift rotas indicated that normal staffing levels were one registered nurse and six care staff on duty during the morning, one registered nurse and four care staff during the afternoon and evening and one registered nurse and two care staff during the night. The registered manager’s and deputy manager’s hours are in addition to these. Staff are employed to carry out domestic tasks, leaving care staff to provide personal care and support to residents. The pre inspection questionnaire recorded that agency staff are sometimes used to cover any shortfall in care hours. The registered manager said that when there was a need to use agency staff, the same agencies were contacted and whenever possible, the same staff from the agencies were used. Staff said they felt the management of the home was extremely supportive in encouraging them to develop their skills. The pre-inspection questionnaire recorded that more than 50 of care staff have obtained a National Vocational Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 21 Qualification (NVQ). This exceeds the minimum standard. Certificates were seen on some staff files and some staff spoken with confirmed they had either completed this qualification or were thinking about doing it. The home has a robust employment procedure. The files of two staff were viewed to evidence the procedure being used in practice. Both files contained evidence that the relevant checks had been completed prior to employment. For example, both had two references, criminal records bureau (CRB) and protection of vulnerable adults (POVA) checks. Both applicants had completed an application form and attended an interview. One of the new staff was working in the home at the time of the inspection and confirmed she had been required to provide information about her previous employment and experience. The registered manager said all new staff were required to complete an induction programme, which will be tailored to their individual previous experience and learning needs. The foundation and induction courses are in line with the Skills for Care programme and are linked to NVQ studies. Staff are required to complete a workbook to demonstrate their understanding of the modules as they complete them. Staff confirmed they had completed an induction programme before being assessed as competent to work with residents unsupervised. Staff felt they were encouraged to ask for specific training and had the opportunity to attend a wide range of courses. Recent training staff said they had attended, or listed in the pre inspection questionnaire included manual handling, first aid refresher training, fire training, wound management, and behaviour management. The registered manager said individual training needs are assessed during supervision and monitored using a training matrix. Appropriate courses, in house and external, are then identified and planned in. Future training planned as listed in the pre inspection questionnaire included mandatory training such as further first aid fresher courses and food hygiene, and service specific training such as palliative care, dementia training and protection of vulnerable adults. Devenish House DS0000039639.V320757.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 home is well managed and there are systems that enable residents to give feedback about the service they receive. There are systems to make sure health and safety issues are addressed and residents are protected. EVIDENCE: The registered manager is a qualified nurse with many years experience in providing nursing care in a residential setting. She has successfully completed a Post Graduate Diploma in Health Management. Her hours are exclusively allocated to the day-to-day running of the home and an administrator and the deputy manager support her in this role. The registered manager operates an open door approach to management and during the inspection it was evident that there was a relaxed atmosphere between her and the staff and residents. Residents and visitors were seen coming to speak to her and she spent time discussing their concerns with Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 23 them. Five staff members commented on the support they received from the registered manager and felt they were enabled to contribute to the running of the home. For example, staff recently fed back that they felt bereavement training should be included in the induction of new staff and this was being arranged. The home has good systems in place to audit the quality of the service and to give residents the opportunity to express their views on the running of the home. The deputy manager is responsible for completing regular audits of systems such as care plans and the management of medication. Feedback is sought informally through daily chats and meetings with the residents, who request changes, such as having supper in the upstairs lounge. On a formal basis, feedback is requested through questionnaires sent out throughout the year. This survey is linked to specific standards from the Care Standards Act 2000. The information is collated and a report produced for everyone to see. Feedback from the survey completed in August 2006 was very positive with residents very satisfied with the service they received. Staff also completed a similar survey and feedback from both residents and staff contributed to the home’s annual development plan. Residents said they either managed their finances themselves or asked a relative to do so, but asked the home to hold small sums on their behalf so they could pay the hairdresser or chiropodist. Individual written records were kept of income and expenditure, together with any receipts. Two signatures were required for any transaction and the records were regularly audited. Discussions with staff, staff training records and information in the pre inspection questionnaire demonstrated that all staff received mandatory training and refresher courses such as infection control, food hygiene and moving and handling. There was evidence the registered manager ensured the health and safety of residents and staff were maintained. For example, hazardous substances such as cleaning products were stored safely. Staff were seen checking hot water temperatures, and thermostatic control valves were installed on all hot water outlets. Window restrictors were fitted to upstairs windows and radiators were covered to prevent the risk of accidental burns. The pre-inspection questionnaire listed contracts for the servicing of equipment and a number of maintenance certificates were seen during the inspection. Devenish House DS0000039639.V320757.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 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 4 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 Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Devenish House DS0000039639.V320757.R01.S.doc Version 5.2 Page 27 - 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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