Inspection on 18/10/05 for Devereux House

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Devereux House 31/10/06

Devereux House 31/05/05

Devereux House 21/12/04

Devereux House 16/06/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Devereux House 69 Albert Road Farnborough Hampshire GU14 6SL Lead Inspector Liz Palmer Unannounced Inspection 18th October 2005 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Devereux House DS0000012109.V259342.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. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Devereux House Address 69 Albert Road Farnborough Hampshire GU14 6SL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01252 512 967 Farnborough and Cove War Memorial Hospital Trust Mrs Sandra Carter Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16), Physical disability over 65 years of age (5) of places Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2005 Brief Description of the Service: Devereux House is a care home providing care and accommodation for 16 older persons. The home is owned and managed by the Farnborough and Cove War Memorial Hospital Trust. Devereux is located in a quiet residential area near the centre of Farnborough, within easy access of all the local amenities. Accommodation is provided on the first floor with the ground floor being used as a day centre. The home has private enclosed gardens that are accessible to service users. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the second unannounced of 2005/2006. Any key standards not assessed on this occasion were assessed at the last inspection, therefore this report should read alongside the previous report. Four and a half hours were spent at the home during which time six residents were spoken to, four care staff and the acting manager and responsible individual. The registered manager is currently off work due to long tern illness. The acting manager is running the home, in general, very well but needs more support from the responsible individual to assist her. Residents in the home are very happy with the management arrangements as are the staff. Residents spoke highly of the care they receive saying things like ‘you could not find better staff anywhere’ and ‘anything you want they will help, nothing is a problem’. All residents spoken to said they feel in safe hands and are confident in the staff and the safety of the home. What the service does well: What has improved since the last inspection? Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 6 The previous requirement regarding a risk assessment has been met. The fire exits have been alarmed to ensure the safety of residents at all times. Residents have enjoyed a few trips out during the summer. 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. Devereux House DS0000012109.V259342.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 Devereux House DS0000012109.V259342.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): 3. Standard 6 does not apply. Arrangements for assessing residents prior to moving in are in place to ensure their needs can be met in the home. EVIDENCE: The home follows an A-Z guide for taking enquiries through to admitting residents. Suitable assessments are currently undertaken by the acting manager. Prospective residents are invited for two respite visits before admission based on a month’s trial period. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 9 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): None of these standards were assessed. EVIDENCE: Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 10 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): 14 The home enables residents to exercise choice and control. EVIDENCE: Residents spoken to said they are able to handle their own finances or are supported by their families. Each has lockable storage in their rooms to provide security for any money or other valuables. Residents also said they were able to bring in personal belongings, for example, items of furniture, for their comfort. Staff were able to give other examples of how choice is promoted in the home, for example, through being involved in developing their care plans. Residents asked said they felt in control of their lives in the home. Residents said they were aware of their care plans and other records and knew that they could have access to them if they wanted to. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 11 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 Staff training and a review of the home’s abuse policy would promote the protection of residents. EVIDENCE: The home has an in-house abuse policy which is due to be reviewed. Some of the wording appears to contradict the Hampshire adult protection policy, which the home also uses. A recommendation to review and reword the in-house policy has been made. Training records show that not all staff have had adult protection training. A requirement has been made for this to be undertaken. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 12 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): 19 Arrangements for maintaining the home ensures residents live in a safe environment. EVIDENCE: The home is suitably furnished and maintained to a high standard. A maintenance person is employed by the home. Records showed that requests for work are attended to promptly with more urgent matters taking priority. The grounds are safe, tidy and well maintained. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 13 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): 27, 28, 29 and 30. Residents needs are met by the numbers and skill mix of staff. Improvements to training would promote the safety of residents and ensures staff are competent to do their jobs at all times. Recruitment procedures must be tightened up to ensure the protection of residents. EVIDENCE: Rotas showed that sufficient staff are on duty at the times they are needed. Staff spoken to, demonstrated their competency and residents said they felt in safe hands at all times. The homes’ training policy states it aims to meet the standard in terms of NVQs. The standard of 50 of it’s care staff being qualified to NVQ level 2 had been met. Some of the qualified staff have left so new staff are enrolled on NVQs to ensure the quota is met. A suitable induction programme is in place. Staff on the induction spoke highly of the training and support they had received so far. The recruitment procedure for the home clearly states the steps to be followed to ensure the standard is met. Staff files of two long term staff showed that the procedure was followed and the necessary checks were undertaken. The files of two new staff were found to contain only one written reference and no records of CRB or POVA checks. This was discussed with the acting manager who was not fully aware of the recruitment procedure, nor who was responsible for what. The acting manager had not received suitable training Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 14 or support in the recruiting of new staff. A requirement was made for all new staff to have the appropriate checks before starting work. The two staff already employed will not continue working until the necessary checks are in place. A requirement was also made for the responsible individual for the home to provide more support and training to enable the acting manager to carry out their role. The support will include keeping up to date with new developments relevant to the running of a home and sharing the knowledge with the acting manager. The responsible individual agreed to this during the inspection and agreed for the acting manager to enrol on the NVQ level 4 in management. Apart from the already mentioned adult protection training staff training is ongoing in the home and suited to the needs of the residents. Residents spoken to said they were aware of staff training taking place and felt staff were qualified and competent to give them the support they needed. Staff spoken to confirmed they had received the training recorded and spoke highly of the training and support they received during their NVQs. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 15 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, 35 and 38 Extra support needs to be given to ensure the temporary arrangements for the management of the home do not impact on the smooth running of the home. Suitable procedures are in place to safeguard the financial interests of residents. The arrangements for health and safety promote the welfare of residents. EVIDENCE: The registered manager is currently off work due to illness and it is unclear when she is planning to return to work. An acting manager, who was previously a senior is running the home. The home is, generally, being run very well but more support is needed for the acting manager to enable her to do her job. This has been discussed and agreed with the responsible individual. Staff spoken to said they are happy and confident about the current arrangements. Each is clear about their own roles and those of the Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 16 management. Residents also spoke highly of the acting manager and said they felt in safe hands and were confident about their safety and well being. Residents spoken to said their families support them with their financial affairs. Only one resident is supported by the home. The procedures for this, as described by staff appeared to be in order. The health, safety and welfare of residents and staff is upheld by suitable training and in house policies and procedures. For example, staff are trained in health and safety, first aid, food hygiene and manual handling. Residents said they feel that the necessary safety precautions are in place, for example, there are regular fire drills. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 17 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 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 3 Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 18 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 2 3 Standard OP18 OP29 OP31 Regulation OP13 OP19 OP38 Requirement Adult protection training must be provided for all staff. All new staff must have two suitable references and a POVA first check before starting work. Training and support must be given to the acting manager. This will include keeping up to date with all new relevant best practice and being aware of all in house policies. Timescale for action 01/12/05 19/10/05 19/10/05 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 OP18 Good Practice Recommendations When the in house abuse policy is reviewed, it is recommended that the wording be changed to ensure consistency with the Hampshire adult protection policy. Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Devereux House DS0000012109.V259342.R01.S.doc Version 5.0 Page 20 - 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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