Inspection on 31/10/06 for Devereux House

This inspection was carried out on 31st October 2006.

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 18/10/05

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 Michael Gough Unannounced Inspection 31st October 2006 10:00 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.V312190.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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 To be confirmed 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.V312190.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 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 House 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. Fees at the home range from £430 to £550 per week and service users are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at Devereux House and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out on the 18 October 2005. Included in the inspection was an unannounced site visit to the home, which took place on the 31 October 2006, the inspection took place over 5.5 hours. Evidence for this report was obtained by speaking with the homes manager, who assisted the inspector throughout the visit, from reading and inspecting records, touring the home and from observing the interaction between staff and service users. It was also possible to gain the views of people living at the home and the inspector had the opportunity to speak with 5 service users also 2 members of staff. The home is registered to provide support for 16 service users but at the time of the inspection there were only 9 service users living at the home. What the service does well: What has improved since the last inspection? Since the last inspection the home has improved its recruitment process and the manager has been supported to carry out her role. All staff has had training with regard to adult protection and a number of rooms have been decorated. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 6 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.V312190.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. New service users have a needs assessment undertaken prior to moving into the home this allows both the home and the service users to see if the home can meet the service users needs. The home does not provide intermediate care. EVIDENCE: The homes manager carries out an individual needs assessment prior to any service user moving into the home using an assessment form to obtain all relevant information. Social services also carry out assessments for anyone who is funded by the local authority. Assessments were on file at the home and service users spoken to confirmed that someone from the home assessed their needs before they moved into the home. Intermediate care is not provided by the home. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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): 7, 8, 9 & 10 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. The health, personal and social care needs of service users are set out in an individual plan of care, which give details of the care to be provided and also gives details on how this care should be given. The home ensures that all service users have access to all relevant health care professionals and the health care needs of service users are met. Service users are protected by the home policies and procedures for dealing with medicines and service users at the home are treated with dignity and respect and their right to privacy is upheld. EVIDENCE: The inspector looked at care plans for 3 service users and these were clear and easy to follow and contained relevant information and informed staff of individual needs and how these should be met. Care plans included risk assessments for service users, with information to identify how risk can be minimised. Day to day recording was clear and concise, and there was clear information that when service users were feeling unwell, staff followed this up Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 10 and the GP was called if necessary. There was also information on service users preferences including getting up and going to bed. Service users at the home are registered with a number of different GP’s and service users may keep their own GP if they wish. Dental checks are arranged through service users own dentist in the local area. Eye checks are also carried out in the local community although a visiting optician service is available. One service user who is diabetic receives free podiatry treatment through the NHS, while other service users use the visiting chiropodist. Service users are supported to access other health care professionals through a GP referral. The home has a policy for the receipt, storage, return and administration of medication and medication records inspected were clear and up to date. The home currently has no controlled drugs however suitable storage is available and the manager is aware of her responsibilities in this area. Only senior staff at the home administers medication and these staff members have undertaken suitable training. Service users spoken to said that staff were always happy and cheerful and said that the care they receive at the home was first class they stated that they were always treated with dignity and respect and It was clear through observations made by the inspector that service users and staff get on well together. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is “Adequate”. This judgement has been made using available evidence including a visit to the service. The home provides a range of activities for service users, which meet their expectations and the religious and recreational interests of service users at the home are provided for. Service users are able to maintain contact with family and friends and visitors are welcome at any time. Service users are supported to exercise choice and control over their lives as much as possible. Service users are provided with a balanced diet in pleasant surroundings at time convenient to them, however service users are not able to have any input into the planning of menu’s and their views are not taken into account. EVIDENCE: Care plans for service users contained information on leisure activities and hobbies and interests and on the day of the inspection there was an armchair aerobics session taking place. At least one recreational or physical activity is offered each afternoon and these include physiotherapy, arts and crafts, games and visiting entertainers. The home is situated above the day service and some service users choose to go down and take part in the activities provided in the day service. A local vicar visits the home on a regular basis and a visiting library calls every 3 to 4 weeks. Photos displayed in the home Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 12 showed residents going out for the afternoon to garden centres and stately homes. The inspector had the opportunity to speak with 5 service users who all stated that they were happy with the activities provided by the home some residents said they enjoyed the activities offered, other said they appreciated being able to choose not to join in. The home has a visiting policy and there are no restrictions on visitors and service users spoken to say that their visitors were always made welcome by the staff. Service users spoken to confirmed that they are able to make informed choices and were able to control their own lives as much as possible. The inspector observed staff and service users interacting and service users were consulted regularly and the staff at the home respected their views. Staff were observed knocking on service users doors before entering and a number of service users had brought some of their own possessions into the home and rooms had been personalised. Breakfast is provided from a small kitchen in the home and the evening meal is a snack type meal such as cheese on toast, scrambled egg on toast or sandwiches. The main meal of the day is taken at lunchtime and this is provided from the main kitchen, which is situated downstairs in the day centre. The day centre also provides a “meals on wheels service” and also provides lunch for people using the day service. Lunch for the care home is provided on a heated trolley and is sent up to the home in trays and is plated up individually by care staff. On the day of the inspection lunch was roast lamb with potatoes, cauliflower and cabbage, with a vegetarian option also available. Once service user requested corned beef with mashed potato, as she did not like the choice available. All of the service users spoken to said that the food provided was not home cooked but frozen and reheated by the kitchen, the inspector noted that the roast lamb was sent up in a foil tray and appeared to be a catering pre prepared pack and the vegetables did not look appetising. The inspector spoke to the homes manager about service users being unhappy with the meals and she said that this was a problem that she was trying to address, she said that the day service kitchen was always very busy and that although some meals are pre packed they are nutritious. She was aware that service users were not always happy with the meals provided but said the kitchen area in the home was not suitable to provide a cooked lunch. It is a requirement that the home must ensure that service users are involved in the planning of menus for the home and that the home operates a quality assurance system so that service users are consulted regularly on the meals they receive and that their views are recorded, taken into account and acted upon. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. There is a simple, clear and accessible complaints procedure, which service users understand and this includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures protect service users for any form of abuse. EVIDENCE: Service users spoken to were confident about raising any concerns they may have and stated that they would address any complaint they may have to a staff member or to the homes manager. The home has a policy and procedure for dealing with any complaints and this contained all of the required information and gave details of how to contact the CSCI. Staff members spoken to were also aware of the complaints procedure. Staff have received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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 the following standard(s): 19 & 26 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Service users live in a safe, well maintained environment and have access to comfortable indoor and outdoor facilities and the home is clean pleasant and hygienic. EVIDENCE: A tour of the home was undertaken and all areas of the home were clean and tidy and furniture was in a satisfactory state of repair. Service users have access to suitable indoor and outdoor facilities and some service users were seen to be using the communal lounge in the home, although others preferred to stay in their rooms. At present one of the bathrooms at the home is not is use as the home is having this bathroom converted into a shower room. The laundry at the home is situated down stairs in the day service part of the building, but this was available at all times and has surfaces, which are easily cleanable. There are 2 washing machines that can wash clothing at suitable Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 15 temperatures and also 2 tumble driers. The home has infection control policies and procedures in place and suitable protective clothing is provided for staff. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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): 27, 28, 29 & 30 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. The home has mix of staff that has a range of skills and there were sufficient numbers of staff on duty to meet the needs of service users. The homes recruitment policy and practice supports and protects service users. Service users benefit from a staff team that has had sufficient training to meet the needs of service users and they are competent and qualified. EVIDENCE: The inspector looked at the homes rotas and these showed that sufficient staff are on duty at the times they are needed, normally there are three staff members on duty in the mornings, with a minimum of 2 staff members on duty at all other times. At night there is one staff member awake at night, backed up by a sleep in member of staff. Staff spoken to said that staffing levels were sufficient and service users said they felt in safe hands at all times. The home employs a total of 12 care staff and 3 members of staff have completed NVQ2 and 4 staff members are undertaking NVQ3. The home has policies and procedures in place with regard to recruitment and staff recruitment records were inspected for 3 staff members and those seen contained all the required information including 2 references and a record of CRB checks. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 17 Staff training records were looked at and this showed that staff have received mandatory training in first aid, food hygiene, moving and handling, fire and adult protection. Additional training is also provided including, medication, continence, care practices, dementia care and infection control. A suitable induction programme is in place and staff spoken to confirmed that they have received appropriate training. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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, 33, 35 & 38 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Suitable management arrangements are in place and the home is run in the best interests of service users. The home has a quality assurance monitoring system to obtain the view of service users at the home and service users financial interests are safeguarded by the home financial procedures. The health safety and welfare of service users and staff are promoted and protected. EVIDENCE: The home has a manager in place who was previously the acting manager for approx 2 years, she is experienced in running the home and is currently undertaking NVQ4 and is waiting to start the Registered Managers Award. The views of service users are taken into account and regular service user meetings are held and these are recorded and this provides information on Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 19 how the home is meeting service users needs. The home will be issuing questionnaires to relatives shortly to obtain their views. Service users manage their own finances as much as possible with the help of relatives and friends and the home does not keep money for service users, any items required are billed to service users or relatives and appropriate records and receipts are kept. Certificates were seen for the annual tests of fire fighting equipment, fire alarms, gas safety; electrical wiring, lifts and bath hoist and these were all in date. The fire log was inspected and all relevant training and testing is carried out within the specified timescales. Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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. 1. Standard OP15 Regulation 16(2)(i) 12(2)(3) Requirement It is a requirement that the home must ensure that service users are involved in the planning of menus for the home and that the home operates a quality assurance system so that service users are consulted regularly on the meals they receive and that their views are recorded, taken into account and where service users have expressed dissatisfaction, this must be acted upon. Timescale for action 01/12/06 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 Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Devereux House DS0000012109.V312190.R01.S.doc Version 5.2 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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