Inspection on 10/11/05 for Devenish House

This inspection was carried out on 10th November 2005.

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 01/02/07

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 Marilyn Lewis Unannounced Inspection 10th November 2005 09:30a 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.V262010.R01.S.doc Version 5.0 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.V262010.R01.S.doc Version 5.0 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.V262010.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd June 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 also registered to admit residents with terminal illness. The home is within 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 first floor, a dining room on the ground floor and small sitting areas are provided on each floor. Devensih 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 the elderly in Winchester, provided by a Christian organisation, the St Johns Winchester Charity. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 10th November 2005. The inspector toured the home and met with eight of the twenty residents, two visitors, three staff members, the cook and the registered manager. Care plans were sampled for two residents and records were seen for medicines, staff training, fire safety and fire drills. This was the second unannounced inspection for 2005/2006. Information on standards not assessed on this occasion can be found in the inspection report dated 3rd June 2005. What the service does well: The home looked clean and welcoming and had a relaxed, friendly atmosphere. Prospective residents and their relatives are provided with clear information about life at the home and are able to visit before making a decision about residency there. Individual care plans are in place for each resident. The plans provide good information on all aspects of the resident’s care needs and enable staff to fully support them. Residents are protected by the home’s very good procedures for dealing with medicines. Residents feel they are treated with respect at all times. Residents can choose to participate in a wide range of social activities, are able to receive visitors as they wish and are offered well presented meals. Residents are protected by staff awareness of abuse issues. Residents are supported by staff who receive the training required to be able to fully meet their care needs. The home is well run and residents benefit from the open approach to management operated at the home and know that their opinions are listened to and acted upon. Residents health, safety and welfare is protected by the safe working practices operated in the home. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 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. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 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.V262010.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 and 6 Prospective residents and their relatives are provided with clear information about life at the home and are able to visit the home before making a decision about taking up residency there. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide clear information about life at the home. The documents contain a brief background of the charity that operates Devenish House, the organisational and staffing structures in place and the services offered at the home. Details of the accommodation are included and also the criteria and procedures for admission, which includes a full care needs assessment undertaken by the registered manager or senior member of the nursing team. The documents are available for all prospective residents and their relatives or representatives. Prospective residents and their relatives/representatives are encouraged to visit the home before making a decision about taking a place there. This gives Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 9 them an opportunity to meet staff and residents, to see their room and discuss the services provided. Devenish House does not provide intermediate care and therefore standard 6 does not apply to the home. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Good information provided in the care plans enables staff to fully support the residents who are treated in a friendly, respectful manner. Residents are protected by the home’s clear procedures for dealing with medicines and those who wish, if assessed as safe to do so, may be responsible for their own medicines. EVIDENCE: The care plans sampled for two residents were good and provided staff with the information required for them to fully support the residents. The care plans contained risk assessments including those for falls, mobility and nutrition. The care plans seen showed evidence of the residents’ involvement in the development and review of the documents. The care plans seen indicated that staff sought advice and support from GPs and other health professionals such as district nurses, Macmillan nurses and speech therapists. One resident had been referred to a clinic for advice on mobility issues and another had attended a clinic for treatment for leg ulcers. At the time of the inspection the chiropodist was visiting the home and residents can also visit a local clinic if they wish. Residents also visit their own Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 11 dental surgery or if they prefer are visited by the dentist at the home as required. The registered manager said that staff escort residents who wish attend opticians in the city centre and this provides an opportunity to make the visit more social by going for coffee. The home has very clear procedures in place for dealing with medicines. Two staff members check and record all the medicines that come into the home. A new system has recently been put in place for the disposal of medicines and this again is checked by two staff members. Medication records seen had been completed appropriately. Records seen for medicines stored in the controlled medicines cupboard matched the stock held. The home has up to date information on the medicines used in the home. 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 an assessment is also 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. During the visit to the home staff were seen to knock on doors and wait before entering rooms. Residents received personal care and visits from the chiropodist in the privacy of their own rooms. Staff were observed interacting with residents in a friendly, caring manner and six residents spoken to during the visit said that staff treated them with respect at all times. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents are able to exercise control over their lives and can choose to participate in a wide range of social activities, receive visitors as they wish and are offered well presented meals. EVIDENCE: The inspector met with a carer, who is also employed as one of two activities co-ordinators, who organise a programme of activities for the residents. The activities programme for the week was displayed on notice boards around the home. Activities include Songs of Praise, quizzes, crafts and videos. Some residents go to see films in the cinema situated close to the home and later in the week some were attending a show at the local theatre. The home had recently held a firework and supper night to which relatives and friends were invited. On the day of the inspection a coffee morning and tombola was taking place. Residents attending commented on their enjoyment of the event. Very good interaction was seen between staff and the residents. Some staff members had come in to join with residents for the coffee morning on their day off duty. The registered manager said that staff are flexible with their hours to allow for additional staff when events are taking place. A carer who is a key worker for a husband and wife who are resident at the home, recently organised a special Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 13 tea party for them and their family, to celebrate their Golden Wedding Anniversary. The Charity’s Chaplin visits the home frequently and holds a weekly service for those who wish to attend. Boys from Winchester College visit the home on a regular basis to support residents with some of the social activities and recently they had entertained the residents with poetry readings. Arrangements are also in place for some of the residents to visit the college to attend a tea party and hear the college choir. The registered manager said that there were no restrictions to visiting hours. This was confirmed by a relative visiting at the time of the inspection who said that she was always made to feel welcome at the home. It was evident from reading the care plans and during the visit that residents are able to exercise control over their lives. One care plan seen recorded the residents wish not to attend a social event and another stated the name by which the resident preferred to be known. One resident said that she was asked if she would like to join in with activities and staff respected her wishes if she preferred to sit quietly in her room. Menus seen indicated that a variety of nutritious meals are offered to residents. Lunch on the day of the inspection consisted of roast beef or a vegetarian option of nut roast, with Yorkshire pudding, creamed and roast potatoes, carrots, swede and parsnips followed by fresh fruit salad. The menu for supper was tomato or watercress soup, and a choice of sandwiches, with pears and custard for desert or cheese and biscuits. Meals served at lunch looked well presented and residents spoken to in the dining room all said they were enjoying their meal. One resident said that although a choice was offered for supper, only a main meal or vegetarian option was available for lunch. The cook and the registered manager said that there were always other options available such as omelette, chicken or salad and every effort would be made to provide the resident with a meal of their choosing. However this was not indicated on the menus displayed. The registered manager said that the menu choice would be made clearer for residents. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents are protected by staff awareness of the procedures to be followed should abuse be suspected. EVIDENCE: The home has procedures in place to be followed should abuse be suspected. The procedures had been reviewed in April 2005 and the registered manager said that the updated procedures had been discussed with all staff members. Staff receive training on abuse issues during induction and when studying for NVQs. Two staff members spoken to during the inspection, knew about the procedures and indicated that they would have no hesitation in reporting any concerns. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 19 to 26 were included in the report of the last inspection, dated 3rd June 2005. All the standards were met. At the time of this inspection the home looked clean and homely. The roof was currently being renewed and this had caused a leak in one bedroom. The resident had been moved to another room while work to repair the damage and redecoration was taking place. Since the last inspection the exterior of the property had been redecorated and new garden furniture had been provided. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30 Residents are supported by staff who receive the training required to be able to meet the needs of the residents. EVIDENCE: The charity employs a trainer to be responsible for staff training. The trainer works with new staff members as they go through their foundation or induction training. The registered manager said that the course they start with is dependant on their previous experience in providing care. The foundation and induction courses are in line with the Skills for Care programme and is linked to NVQ studies. Currently 14 of the 23 carers hold NVQ level 2 or above and 3 are in the process of studying for the qualifications. Two of the carers are also NVQ assessors and one of the activities co-ordinators has an NVQ level 3 in promoting independence. A cleaner has also gained an NVQ in cleaning procedures that included infection control. The deputy manager and a carer have received training that enables them to teach staff in the home moving and handling techniques. All the trained nurses have attended a four day first aid course and carers do one day courses as part of their NVQ. Only staff members who have attended first aid training are permitted to escort residents on trips out of the home such as into town for shopping. Kitchen staff and carers who work on the day and evening shifts have all received food hygiene training and arrangements are in place for an update on infection control. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 17 Trained nurses attend training sessions for their professional development requirements. Recent training sessions have included the care of leg ulcers and palliative care. Three staff members spoken to during the visit said that they were encouraged by the registered manager to attend training sessions and to gain qualifications. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 38 The home is well run and the residents benefit from the open approach to management in place and their health, safety and welfare is protected by the safe working practices operated in the home. 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. 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. Three staff members commented on the support they received from the registered manager. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 19 During June 2005 the home conducted a survey on the quality of care provided at the home. The completed survey questionnaires were seen during the inspection. The results indicated that the residents were very satisfied with the care provided. The registered manager said that the results indicated that since the last survey, a year ago, there has been an improvement in staff offering choice and the quality of care provided. The home had acted upon comments made in the last survey and had worked to improve the areas high lighted by residents as satisfied and not marked as very good or good. Fire records seen indicated that all staff receive fire safety training and attend fire drills. Staff received training in mandatory subjects including moving and handling, food hygiene, first aid and arrangements were in place to up date infection control training. Health and safety notices were displayed in the home and during the inspection it was noted that hazardous substances such as cleaning fluids were stored securely. The kitchen looked clean and in good order with food stored appropriately. Current certificates were seen for the servicing of equipment including the hoists, lift, air conditioning, fire safety equipment and for the electrical and water systems. Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x x X 3 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 x 17 x 18 3 x x x x x x x x STAFFING Standard No Score 27 x 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x x x 3 Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 21 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 Devenish House DS0000039639.V262010.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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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