Inspection on 03/06/05 for Devenish House

This inspection was carried out on 3rd June 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 10/11/05

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 03/06/05 9:30 a.m. 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 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 H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Devenish House Address 49 Southgate Street Winchester Hampshire SO23 9EH Telephone number Fax number Email 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 Johns Winchester Charity Mrs Joanne Marie Croft CRH 21 Category(ies) of OP Old age T(E) Terminally ill registration, with number of places Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11/01/2005 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 H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on the 3rd June 2005. The inspector had the opportunity to tour the home and to meet with six of the twenty residents, four carers, the deputy manager and the manager. The inspector also looked at care plans, staff records, medication records, the complaints record, staff rotas and the fire records. What the service does well: The home has a relaxed and friendly atmosphere and the open ethos ensures that residents feel able to voice their opinions freely. During the inspection visit residents were very positive about the caring attitude of the staff. Some of the comments made were ‘ the staff are lovely, always treat me with respect’, ‘Carers are tops, I couldn’t have gone to a better home’ and ‘I can’t fault the home or the staff’. Thirteen comment cards sent to the Commission also gave positive feedback about the good quality of care provided at the home. Good care plans are developed and reviewed in conjunction with the residents or their relatives, providing staff with clear information and enabling them to give the support required to meet the residents’ needs. The staff follow excellent procedures when dealing with medicines. The robustness of the procedures minimises any risk to the residents of an error occurring in the administration of medicines. Residents are able to enjoy a choice of good nourishing meals in a friendly relaxed atmosphere. Residents live in a clean, safe, homely and comfortable environment. The open ethos of the home and sound procedures for dealing with complaints ensures residents feel able to complain if they so wish and know that the complaint will be investigated thoroughly. The registered manager of the home provides staff with strong leadership and support and that has helped to build a caring and dedicated staff team. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 H54 S39639 Devenish V224028 030605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 standard(s) 2 and 3 Prospective residents and their relatives are ensured that the home can meet their needs by the provision of a clear written contract and the undertaking of a detailed full needs assessment. EVIDENCE: Each resident is provided with a clear contract giving details of the terms and conditions for residency at the home. The resident or a family member is asked to view the room for occupation prior to admission and this room number is stated in the document. Services such as chiropody and hairdressing that require additional payment are listed in the contract. The contract also states that the home will respect cultural or religious beliefs. Prospective residents are visited by the registered manager or senior member of the nursing team prior to admission for a full needs assessment to be completed. Assessments seen for three residents were good and included all aspects of care needs including personal care, mobility, communication and medication. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 9 Relevant information from care managers and health professionals was included in the completed assessment report. Relatives are encouraged to participate in the assessment process. Since the last inspection the occasional completion of full needs assessments using a questionnaire and telephone conversation only, has ceased and all prospective residents are now visited at home or in their place of residence. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 standard(s) 7, 9 and 11 Good care plans, excellent medication procedures and sensitive policies for caring for the dying indicate that the home provides high quality care throughout the residents’ stay at the home. EVIDENCE: Care plans were seen for five residents were good. The preferred name for the resident was noted and the plans included details of the care and nursing needs and the support required to meet those needs including personal care, eating, mobility and nutrition. The plans contained risk assessments for pressure areas, falls, mobility and specific areas of concern for individual residents such as anxiety and the management of the use of oxygen. The residents hobbies and interests were documented as were their likes and dislikes for food items. The plans showed evidence of the resident or their relatives involvement and had been reviewed monthly. The deputy manager audits the care plans three monthly. The registered manager said that it was difficult to gain access to the services of a dietician for residents with low body weight. All avenues were being Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 11 explored and the home was completing a nutrition risk assessment for residents. Staff follow very thorough procedures for dealing with medication. Only trained nurses administer medicines and medication records seen were up to date and had been completed appropriately. Records checked for controlled medicines matched the supply held. The home has procedures in place for residents who wish to administer their own medicines. The deputy manager said that the residents’ GP is asked to confirm that they are satisfied the resident is able to safely administer their own medication and an assessment is also completed by a trained nurse. Any change in the ability to self-administer medication is noted and acted upon. Residents are provided with a lockable storage space to store medicines in their room if self-administering medicines. The home has a sensitive policy for caring for the dying, which includes understanding the emotional stages and recognising signs of strain on relatives and colleagues. Relatives are able to stay at the home for as long as they wish and are provided with a bed and shower facilities if required to stay overnight. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 standard(s) 12,13 and 15 Residents are able to participate in a variety of social activities, including visits from relatives and friends and enjoy a choice of good, well presented, nourishing meals in a relaxed and friendly atmosphere. EVIDENCE: The home employs a carer who is allocated hours to work as the activities coordinator. Activities available include quizzes, sing-a-long, videos, brain teasers and songs of praise. Recently a session had been organised for gardening for balconies as some of the residents accommodated at the rear of the building have balconies and enjoy keeping containers of plants and flowers. The inspector met with the Charity’s Chaplain, who visits the home frequently and holds a weekly service for those residents who wish to attend. The service is popular with approximately fifteen residents attending each week. Visitors are welcome at the home at any time although under normal circumstances it is preferred that they do not come late at night. Three residents said that visitors were always given a friendly welcome. Boys from a local college who are participating in the Duke of Edinburgh Award Scheme, visit the home to support residents in some of the activities such as board games. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 13 At the time of the inspection many of the residents were looking forward to attending the wedding of a member of staff due to take place the next day. The cook said that residents’ likes and dislikes for food items were taken into account when planning the menus. Menus seen were varied and interesting and offered choice. There was a good supply of fresh fruit and vegetables available and the cook said that fresh produce was used for most meals. The inspector spent time with some of the residents during lunch. The meals provided were well presented and looked nutritious. The residents were offered a choice of scampi, steamed fish or sausages with chips or mashed potato, peas and grilled tomatoes, followed by bread and butter pudding or fresh fruit salad. Six residents spoken to during the meal said that they had enjoyed their lunch. Homemade cake was on the menu for tea and supper was soup and macaroni cheese. The cook said that some of the residents preferred to have cheese and biscuits for supper and these were always available. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 standard(s) 16 Residents that were spoken to said that they know that any complaints will be taken seriously and investigated thoroughly. EVIDENCE: The home has clear procedures to be followed when a complaint is received. All complaints are taken seriously and records seen indicated that they are investigated within the timescales stated in the procedures. Two complaints had been received in the last year, one of which had been substantiated. The registered manager said that if a resident is admitted who is visually impaired the procedures would be given verbally. Three residents spoken to were aware of how to make a complaint and felt they would be able to do so if the need arose. The residents felt that any complaints made to the registered manager would be acted upon quickly. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24 and 26 The homes’ ongoing maintenance programme, provision of specialist equipment, sufficient bathroom and toilet facilities, homely bedrooms and communal rooms allows residents to live in a clean, safe and comfortable environment. EVIDENCE: On the day of the inspection the home looked well maintained. The charity employs a maintenance team to redecorate and refurbish the home and its other properties in the Winchester area. Access to the home is safe guarded by the use of keypad entry systems. A staff training room and library area are located on the lower ground floor, in an area of the home not accessed by residents. The kitchen and laundry rooms are also located in this area. The home has a large conservatory/lounge that is used for activities and the weekly service is held there. The furniture in the lounge although adequate is Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 16 showing signs of wear and the registered manager said that arrangements were being made to renew some of the furniture in the communal areas. All residents’ bedrooms are fitted with en-suite facilities and additional toilet and assisted bathrooms are situated on each floor. Two of the assisted bathrooms have been refurbished in the last year and there are plans to update the remaining bathroom next year. Specialist equipment such as hoists is provided for residents who have been assessed as requiring them. Grab rails and ramps are in place where required and a passenger lift allows easy access to the three floors used by residents. Residents’ rooms looked homely and comfortable and suited their needs. Some rooms have doors that open out onto balconies. Residents in these rooms have been risk assessed with regard to holding the keys for the balcony doors. Residents are able to bring personal belongings with them and one resident commented on her pleasure at being able to have her own furniture in her room. All residents spoken to liked their room. The home looked clean and fresh, with no offensive odours. Staff received training in infection control and disposable gloves and aprons were readily available for staff. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Robust recruitment procedures and a sufficient number and skill mix of staff ensures the residents’ are well supported and protected. EVIDENCE: The home employs ten trained nurses and twenty-one carers. The registered manager is able to call upon the services of bank staff to cover sickness and holidays but some agency staff are also required. Staff rotas seen indicated that sufficient trained nurses and care staff were on duty for each shift. Separate staff are employed for administration, catering, laundry and domestic duties. The home has robust recruitment procedures in place. Applicants are required to complete a suitable application form and attend an interview with the registered manager. Records seen for four staff members contained all the information required, including two written references, proof of identity and Criminal Record Bureau checks. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 36 and 38 Strong leadership that provides staff with guidance, supervision and support ensures that residents receive good quality care and promotes health, safety and welfare. EVIDENCE: The registered manager is a qualified nurse with many years experience in providing nursing care in a residential setting. She has recently successfully completed a Post Graduate Diploma in Health Management. Four staff members spoken to during the inspection commented on the support and encouragement they received from the registered manager. Meetings are held weekly for carers and full staff meetings quarterly. Trained staff also meet together every six to eight weeks to share and discuss information relevant to the care of the residents that they have researched. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 19 The registered manager said that relatives were invited to attend meetings held for residents, usually on a six monthly basis. The Chaplain attends the residents meetings and acts as an advocate for those without relatives. The registered manager operates an open door policy and all residents and staff spoken to said they felt able to talk to her at any time. Staff also commented on the support they received from colleagues. A questionnaire is provided annually for residents and their relatives to give their opinion on the care provided at the home. Residents who have been staying in the home for respite care are asked to complete a questionnaire on discharge. The registered manager said that any comments were fed back to the residents during meetings. Thirteen residents completed comment cards for the Commission prior to the inspection and all said that they liked living at the home and felt the care provided was good. The registered manager, the deputy and two trained nurses have received training in providing supervision to staff. Staff are given a choice of who will supervise them and sessions are held at least six times a year. The meetings are recorded and the minutes are signed by the staff member and the supervisor. The registered manager said that all staff receive an annual appraisal and this identifies training needs and areas to be covered in future supervision meetings. Fire records seen indicated that all staff receive fire safety training and attend fire drill practices. The registered manager said that staff do not have prior warning about fire drills. A staff member employed from an agency on her first day at the home said that she had been given information regarding fire safety such as where the fire exits and fire extinguishers were before she was allowed to start her shift. Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 4 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 x x 3 3 x 3 Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 21 No 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. 1. 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. 1. Refer to Standard Good Practice Recommendations Devenish House H54 S39639 Devenish V224028 030605.doc Version 1.30 Page 22 Commission for Social Care Inspection 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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