Inspection on 31/05/05 for Devereux House

This inspection was carried out on 31st May 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

Devereux House 31/10/06

Devereux House 18/10/05

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 31 May 2005, 11:00 st 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. Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Devereux House Address 69 Albert Road Farnborough Hampshire GU14 6SL 01252 512967 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) Farnborough and Cove War Memorial Hospital Trust Mrs Sandra Carter CRH 19 Category(ies) of Old Age - OP - 19 registration, with number Physcial disability, over 65 - 5 of places Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21.12.04 Brief Description of the Service: Devereaux House is a care home providing care and accomodation for 19 older persons. The home is owned and managed by the Farnborough and Cove War Memorial Hospital Trust and home is located in a quiet residential area near the centre of Farnborough and is within easy access of all the local amenities. Accomodtation 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 H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours. The focus of the inspection was to talk to residents about life in the home and how their needs are being met. Seven care plans were looked at and four residents were interviewed. There were no outstanding requirements from the previous inspection. One new requirement has been made as a result of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments for service users who self-administer must be drawn up. Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 6 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 H54 S12109 Devereaux House V227306 310505 Stage 4.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 Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.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) None of these standards were assessed on this occasion. EVIDENCE: Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 Residents benefit from the home’s arrangements for care planning. Those requiring them would benefit from suitable risk assessments being in place. EVIDENCE: Seven care plans were looked at and found to be clear, concise and contain all the relevant information, for example, residents’ hobbies and interests, personal care required and religious preferences. Four residents were interviewed and all stated they were very happy with the care provided and comments such as ‘staff are really kind and patient’ and ‘they would do anything for me’ were made about the staff in the home. Residents are all registered with a local general practitioner (GP), some have kept the same one they had for many years prior to admission to the home. Residents told the inspector they can access their GP or could ask the staff to contact them. Suitable procedures are in place for administering medication, for example, the home operates a monitored dosage system. Records and stocks were accurate on the day. One resident self-administers his medication for which a risk assessment needs to be drawn up and a lockable space provided. Another Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 10 service users’ care plan states she self-medicates but no risk assessment had been drawn up to reflect this. Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 11 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 Arrangements for social and recreational activities offer residents a variety of stimulation. Arrangements for meal times are flexible to meet the individual needs of residents. EVIDENCE: At least one recreational or physical activity is offered each afternoon. Residents are encouraged individually to participate and other regular activities also take place, for example, a hairdresser visits weekly and a mobile library also visits. Activities offered in the afternoon include, bingo, physiotherapy and arts and crafts. Photos displayed in the home showed residents enjoying a visit from an animal sanctuary. Outings are also arranged to garden centres and stately homes. Some residents commented they enjoyed the activities offered, other said they appreciated being able to choose not to join in. A suitable visiting policy is displayed in the home. Residents said their visitors are made welcome and are free to visit when it’s convenient to them. Residents are generally happy with the arrangements for food. Lunch on the day looked wholesome and nutritious. One resident stated they would like more fruit and vegetables to be available for health reasons. This was Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 12 discussed with the senior care officer and it was agreed it would be incorporated into their care plan. Residents told the inspector that they have a choice of their main meal which they choose the day before. Meals are prepared in the day centre kitchen downstairs. An agency chef was covering the chef’s annual leave, they said it was one of the cleanest kitchens they worked in. Environmental Health had visited the week before, no requirements were made. Residents have a choice of where to eat. One resident said they like to eat all their meals in their room and this is respected. Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 13 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. The arrangements for complaining enable residents and their representatives to have their views listened to and acted upon. EVIDENCE: A suitable complaints procedure is displayed throughout the home and in residents’ bedrooms. Residents spoken to told the inspector they would feel happy to complain if they had any concerns. Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 14 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) 26 Arrangements for cleaning, decorating and maintaining the home ensures residents live in a hygienic and comfortable environment. EVIDENCE: The home was clean, bright and homely on the day of inspection. All communal areas were furnished and decorated in a comfortable and homely way. Domestic staff are employed and are trained in infection control and aprons and gloves are worn. Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 15 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) None of these standards were assessed on this occasion. EVIDENCE: Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 16 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) None of these standards were assessed on this occasion. EVIDENCE: Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 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 x x x x x x x x Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 18 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. 2. Standard YA9 Regulation 13 Requirement Risk assessments should be drawn up for residents who self administer their medication. Timescale for action 25/08/05 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 Good Practice Recommendations Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Devereux House H54 S12109 Devereaux House V227306 310505 Stage 4.doc Version 1.30 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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