Inspection on 21/05/07 for Devon House

This inspection was carried out on 21st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Devon House 21/04/09

Devon House 22/04/08

Devon House 07/11/07

Devon House 05/05/06

Devon House 24/02/06

Devon House 22/09/05

Devon House 19/10/04

Devon House 17/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Devon House 49 Bramley Road Oakwood London N14 4HA Lead Inspector Wendy Heal Key Unannounced Inspection 21st May 2007 10:30 Devon House DS0000010655.V333457.R01.S.doc Version 5.2 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 Devon House DS0000010655.V333457.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 Adults 18-65. 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. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Devon House Address 49 Bramley Road Oakwood London N14 4HA 020 8447 0642 020 8886 4408 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) www.craegmoor.co.uk Parkcare Homes Limited Mary Bridget Brennan Care Home 14 Category(ies) of Dementia (1), Mental disorder, excluding registration, with number learning disability or dementia (14) of places Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2006 Brief Description of the Service: Devon House is owned by Parkcare Homes Ltd. Devon House is a large, detached, modern house in a residential area of Oakwood. There are fourteen single bedrooms. All bedrooms have en-suite facilities and are located on two floors. The kitchen and dining room are at the front of the house. There is adequate communal space for the number of people and a garden to the rear of the property. The home aims to ensure people are supported to live as independently as possible. The organisations fees range from £692.00 to £715.00. The home has the Purpose and Function Document and Inspection Report on their notice board for interested parties to view. Also accessible on the CSCI website. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards. The inspection took approximately 8 hours. The manager assisted me throughout the day. I undertook a tour of the building, interviewed people living in the home and observed the interaction between people and staff working in the home. Further information was obtained by an inspection of the documentation kept in the home including care plans and health and safety documentation. I would like to thank all of those present for their openness and participation. What the service does well: The staff within the home maintain a good relationship with the people who live there. Staff undertake training to ensure they equip themselves with the skills required to ensure they meet people’s needs. Adult protection documentation in relation to the procedures to be followed are available in the home. Staff have a good understanding of the procedures that need to be followed to protect people from potential abuse. People’s financial records were found to be in order, which means effective recording is taking place and protects people from financial abuse. Recruitment procedures and the required documentation are available and clearly recorded. The quality of food available in the home is good which protects people’s wellbeing. People have access to all the necessary health care professionals which ensures their health care needs are met The complaints book was available for inspection and found to be in order. Medication was stored effectively and clearly recorded which ensures people’s wellbeing is safeguarded. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Detailed assessments must be undertaken when new people move into the home to ensure their individual needs can be met. The homes statement of purpose needs to be updated to ensure accurate information is being recorded in relation to the service. Care plans must be detailed and kept up to date to ensure that an individual person’s changing needs are reflected within them. Key worker meetings must take place as agreed in people individual care plans to ensure people’s needs can be responded to and assist them to feel valued. Risk assessments must be developed in relation to people’s individual risks to ensure that these specific risks are minimised for new people that move into the home. Effective monitoring and recording needs to be in place in relation to the monitoring of people living in the home who smoke in their bedrooms and pose a health and safety risk in relation to the risk of a fire taking place within the home. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 7 Improvements need to be made in relation to a number of environmental issues for example the ventilation in the shower room needs to be improved, the hall carpet needs to be cleaned to ensure the home is a pleasant place for people to live. Regular supervision needs to take place, which will ensure a consistent approach is maintained and that adequate support is provided to staff. All staff vacancies must be advertised and the posts filled to ensure that an established team of people are available to meet people’s needs. The staff rota must be reviewed to ensure that there are adequate staff on shift to meet peoples individual needs. Staff must not work excessively long hours, which may impact on their ability to function effectively. Quality assurance documentation must be available for inspection to ensure that all relevant peoples views are being sought which will provide information in relation to the service were it is doing well and were it needs to improve. All records in the home must be properly organised and completed to enable ease of access to information as required. 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. The summary of this inspection report can be made available in other formats on request. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People do have the information they need to make an informed choice about were they want to live as a service user guide is available. Assessments are not appropriately undertaken prior to people moving into the home to ensure peoples needs can be met. People do not have the opportunity to “test drive” the home to make a decision as to whether they like it or not. EVIDENCE: Since the previous inspection there has been two new admissions to the home. One person has transferred from another home within the organisation at his request and said, “I am very happy here as it is more calm and relaxed.” The second person had been newly referred to the home and adequate documentation was not available in relation to the admission and assessment process. The assessment process identified that the full information was not available in relation to the persons needs to identify that the peoples needs could be met. Some equipment had been obtained by the service such as an electric bed and a chair but an occupational assessment had not taken place or been requested in relation to the person moving into the home to ensure their individual needs could be met. The manager of the home stated that the manager of another service had completed the assessment and that she herself had not received the referral Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 10 until two weeks after the person was admitted to the home. This referral had been requested, by the homes manager from the person’s CPN. I looked at the information provided by the CPN and I believe that the persons health care needs are currently his primary need as the person has Diabetes, mobility difficulties due to excessive weight, cellulites, high blood pressure, a heart condition. The person requires full support in relation to personal care and daily living but additional staffing has not been included as part of the package of care to ensure his individual needs can be met. A more suitable placement needs to be identified, as staff cannot meet the person’s needs. This is an inappropriate placement and does not ensure that this person’s needs can be fully met, which means that the person’s quality of care will be affected. The admission and assessment process could not evidence an overnight stay or an opportunity to test drive the service as the person moved straight to the home from hospital which does not ensure they have the opportunity to see if the service can meet their needs. In this case it was evident that the home was not able to do so. At the time of the inspection the person had been admitted to hospital and the manager of the home having spoken with myself has confirmed that the person will not be returning to the home. I looked at the statement of purpose, which needs to be updated to ensure that accurate information is available in relation to the service as it refers to the previous deputy manager who has now left the home. The service user guide was seen and ensures that people moving into the home and ensures that they have the information they need to enable them to make a choice about were they want to live. I contacted the area manager of the service who has since visited the home and looked at the assessment documentation within the home and discussed this matter with me. The area manager has been invited to a meeting with the Commission for Social Care Inspection to discuss the concerns identified in this report. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Not all of the people’s care plans are being kept-up-to-date, as they do not contain detailed accurate information. People do make decisions about their lives, which empowers them. The service must improve with regard to supporting people to take risks to develop an independent lifestyle to ensure that people’s needs are met and their wellbeing is safeguarded. EVIDENCE: People’s care plans were inspected and were clear to read. One person who was admitted to the home in April 07 does not have a completed detailed care plan in place however this person is currently in hospital and the manager has informed me that the person will not be returning to the home. Care plans are not being updated on a monthly basis and it is noted in peoples care plans that they will have weekly key worker meetings. I asked why one person’s care plan had not been updated and why their key worker meeting had not taken place and was informed this was because the allocated member Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 12 of staff now works nights which does not ensure that the actions agreed in the persons care plans are being carried out and does not ensure the person’s needs are being met. Another person had not had their care plan up-dated since 08/04/06, which, means their changing needs, may not be reflected in their care plan. The care plans were informed by risk assessments. The areas covered included depression, medical appointments, smoking in bedrooms, physical and verbal outbursts and self-neglect. I saw evidence that people are still smoking in their bedrooms. The recently replaced bedroom carpets have burn marks on them and there is a continued risk of a potential fire - taking place. One identified person has burn marks caused by cigarettes being placed above the electrical socket in his bedroom where he extinguishes them in the plug socket. I was informed that this person places his cigarettes in the toaster to light his cigarettes and as a result staff hide the toaster. Staff also informed me that this person gathers cigarettes from the garden and locks himself in the bedroom to have a cigarette. This person’s risk assessment needs to be updated as a matter of urgency to ensure all areas of concern in relation to the risk of fire and action to be taken is included in the risk assessment. On the day of the inspection the recorded room checks that are meant to be carried out by staff to remind people that they must not smoke in their rooms could not be located which means that effective recording and safety checks cannot be evidenced as taking place. This means people’s safety cannot be guaranteed. I discussed the above areas of concern with the area manager of the service who visited the home and discussed her findings with me on the telephone whilst visiting the home. Service users meetings are taking place on a regular basis, which does ensure that people have the opportunity to express their views. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,1315,16,17, Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People are supported to develop their skills within the home, which assists their independence. People are part of the local community, which enriches their lives. People’s rights are respected which increases their self-esteem. People are assisted to maintain appropriate relationships, which assists their emotional wellbeing. People are offered a healthy diet, which promotes good health. EVIDENCE: At Devon House people’s activity records were inspected. The home now has a life skills coach in post who has developed a programme of activities with the people living at the home, which identifies for each person activities such as cleaning their room and undertaking their laundry as well as allocated time for people to cook, play board games such as chess, take part in group discussions. Two people attend community centres and take part in art and craft, yoga, and Indian head massage. I spoke with the people living in the home. One person Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 14 said, “I enjoy the activities I undertake very much”. One person who refuses to take part in activities stated, ”its women’s work. I was informed on the day of the inspection by the life skills coach that she was leaving the service which will limit the opportunities available to people living in the home until a person is recruited to the post. The service does not have a vehicle available to use in relation to day trips or outings, which would benefit people and could be used to encourage them to take part in a range of activities. People’s contact varies ranging from personal visits to the home and stays at the family home to telephone calls and cards at Christmas. On the day of the inspection one person had returned from a stay with his mother. One person has three visits per week from his mother and sisters, which benefits his emotional wellbeing. People have keys to their bedrooms which some of them use which ensures their privacy is respected. There is also acknowledgement of restriction of people’s liberty. This is recorded in peoples risk assessments in relation to staff completing room checks every half an hour in relation to those people who smoke in their rooms. The reason for this is that there is a risk to people in relation to an increased risk of fire taking place in the home. However on the day of the inspection the information to evidence room checks taking place was not available for inspection. On the day of the inspection the kitchen was clean and tidy. The fridges were inspected and food stored in the fridge was labelled appropriately and items stored were within their use by date, which ensures people are not eating food harmful to their health. The menu of food available was wholesome and nutritious which ensures that people’s dietary needs are being met. The food is ordered and delivered to the home. Staff stated,” this is due to the staffing levels”. The home does keep a record in relation to what people have actually eaten. This ensures that their individual diets can be monitored which benefits people’s wellbeing. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s physical health needs are not fully met. People have access to all the necessary health care appointments, which means their individual health care needs are being monitored. The people living in the home are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: People have access to primary and specialist healthcare appointments including general practioners, dentists, opticians, district nurses, psychiatrists, which ensures peoples health care needs are being met. One identified person had not had a bath for the period of one month. I was informed this was because the person became distressed. I could not find any documented evidence in relation to this concern at the time of the inspection. This is inappropriate practice. I looked at the medication records, which were found to be in order and ensure that effective recording is taking place to safeguard the wellbeing of people living in the home. The home also has available the sample signatures of staff who are able to administer medication. The medication cupboard was found to Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 16 be in order and excess medication was not being stored which ensures good practice is being followed. Staff have received training in relation to the administration of medication which further protects people’s health from being at risk in relation to errors being made due to lack of information. People were appropriately dressed at the time of the inspection, which assists them to improve their self-image and feel valued. I looked at the weight charts of people living in the home and they have been kept up-to date which means a consistent approach is now in place in relation to the process to support people with their weight management. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected by trained staff that have an adequate understanding of how to protect people from abuse neglect and self-harm. EVIDENCE: At the time of the unannounced inspection I looked at the complaints file. No new complaints have been made since the previous inspection. The home has a satisfactory complaints procedure. The company policy on whistle blowing was satisfactory and staff are familiar with how to use it which protects the people living in the home from any unprofessional practice. Staff at the home had attended Adult Abuse and protection of vulnerable Adults training and the manager was knowledgeable in relation to reporting procedures. Staff have been provided with the necessary skills to protect people from potential abuse. The home had the necessary adult protection and multi agency documentation, to report any incidents when necessary. Financial records of the people living in the home were inspected and found to be in order, which means that good practice is being followed in relation to the management of people’s money. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,30, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home have benefited from recent improvements in the environment. Although there are still outstanding environmental issues that need addressing. EVIDENCE: Devon House is located in a residential area near to local shops and public transport. During a tour of the building I looked at people’s bedrooms having sought their permission. The people’s bedrooms were not all furnished to suit their needs and items need to be obtained to ensure their individual needs are met. One identified person who brings a garden chair to sit on in his bedroom must be brought an easy chair to ensure that he has the necessary furniture to ensure he is comfortable in his room. The ground floor bathroom, which is being investigated in relation to a water leak, must have the pipes, which have been uncovered recovered. This area Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 19 must be painted once the water leak has been acted upon to ensure that the standard of the home is maintained. The shower on the first floor was clean and in good working order but the manager must ensure the shower is regularly inspected to ensure that mould does not build up and the grout does not become dirty due to poor ventilation in the room. This has been an ongoing problem in the past. The manager explained that she has identified an extractor for the bathroom, which was a requirement at the previous inspection, however work in relation to the installation of this had not commenced. Bedroom 6 must be redecorated, as there are cigarette burns caused by the person placing their lighted cigarette above the electric sockets on the walls and the paintwork is starting to look dirty. The carpet must also be replaced due to the cigarette burns caused by smoking in the bedroom to ensure the person has a pleasant place to sleep. I am concerned that a number of rooms that have been decorated in the past will soon once again require new flooring due to the number of cigarette burns which have made holes in the carpet. Staff must be consistent in relation to room checks and smoking in the bedrooms to ensure this is not an ongoing requirement in relation to redecoration and replacement of flooring, this is essential to ensure that people’s safety is guaranteed. This area of concern was brought to the attention of the area manager who then visited the home to see the concerns for herself. This matter will be further discussed in the planned meeting referred to at the beginning of the report. I am aware that redecoration has taken place. For example, room two has been redecorated and the pillows and quilts have been replaced for all bedrooms, which ensures people’s personal comfort has been guaranteed. Room 7 has had the carpet replaced a short time ago, however this is already showing signs of being ripped and will need replacement in the future. The door lock needs to be repaired to ensure the door can work effectively and the person’s privacy is maintained. The lounge should be scheduled in the maintenance plan for redecoration. The area is starting to show smoke build up on the walls of the lounge, which needs to be acted on to ensure the people have a comfortable place to relax. Room 26 needs the bathroom floor to be replaced, as it is dirty and not hygienic for the person who uses the en-suite bathroom. The hall carpet particularly outside the kitchen area is very dirty and must be professionally cleaned to ensure that hygienic standards are maintained particularly as the carpet has only recently been replaced and is very heavily used in this area of the home. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 20 The person in room twenty-five has had his room decorated and carpet replaced and the excessive items stored in his room reduced. The manager must ensure that these items do not build up to an excessive level again as this then poses a health and safety risk. The kitchen has been decorated the kitchen cupboards have been replaced which has improved the environment in which people live. The dining room floor has been has been replaced and looks more homely. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36, Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. People living in the home are supported by staff that are not fully qualified. The staff team are not a cohesive and are not effective as a number of posts are vacant. People are safeguarded by the home’s recruitment policy and procedures. Not all staff are receiving regular supervision so a consistent approach to work with people cannot be maintained. EVIDENCE: The Registered Manager of the home is leaving her employment after a number of years service. A new manager has been appointed who will have to undertake an induction programme and make an application for CSCI registration. A deputy manager must also be appointed, as this position has been vacant for a considerable length of time. This will ensure the new manager has the necessary support to ensure the home is run effectively. One member of staff is on maternity leave. The two vacant staff posts must also be appointed to to ensure an established staff team is available to provide the necessary support to the people living in the home. The staff rota was inspected and indicated that there were on occasion’s only two staff on duty in the morning and two staff on duty in the afternoon. Staff had also worked two or three long days in a row and a long day starts at seven Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 22 forty five in the morning and finishes at ten in the evening. I was informed that staff were becoming distressed due to the hours worked and the demands placed on them by an identified person who was living in the home. This does not ensure that staff are working in the most effective way to safeguard the health and safety of staff and people living in the home. The staff informed me that most of their time had been taken up with domestic tasks such as cleaning and cooking and this appears to be affecting staff morale. The life skills coach had undertaken activities with people individually and I was pleased to see that the need for this role in the home has been acknowledged. However this person is also due to leave her post. This post will also have to be advertised to ensure that the productive efforts to motivate people living in the home to reach their full potential is continued. Time is allocated to individual people in relation to activities taking place. During my discussions with the area manager I have been informed this post will be advertised. The registered provider should review the staffing levels in the home to ensure that the needs of the people living in the home are met in line with their individual care plans. People are protected by the homes recruitment policies and procedures as all relevant documentation was in place. This included up-to-date CRB checks, and two references, which ensures people living in the home, are protected from potential abuse. Staff had undertaken training in relation to fire awareness, and diabetes. They and are soon to undertake training in relation to manual handling and protection of vulnerable adults which will ensure that staff have received the necessary training to meet the needs of the people living in the home. Staff are undertaking their NVQ level 2, which is near to completion. However when I discussed this with the staff at the home one staff member said, “ the assessor stopped coming to the home in November 2006” I have requested the manager discuss this matter with her line manager to ensure that staff can fully complete their training. Supervision is not taking place with all staff on a regular basis, which means that staff are not being supported to work with people living in the home in a consistent way. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People cannot be confident that their views underpin all self-monitoring review and development. The health safety and welfare of people living in the home is promoted and protected. People do not benefit from a well run home as staff posts are not all recruited to and this impacts on the consistency of the service offered. EVIDENCE: People cannot be confident that their views underpin all self-monitoring, review and development in the home as this documentation could not be located at the time of inspection. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 24 I inspected a range of health and safety documentation, which included fire documentation; fire door monitoring had taken place on the 23/04/07. The fire drill had taken place on the 23/02/07. The weekly fire bell test was last completed on the 14/05/07. The fire alarm had been tested on the 22/03/07. The gas certificate was seen and found to be in order dated 14/07/07. The electrical certificate was seen and found to be in order and was last dated 08/09/07. All of these procedures serve to protect people living in the home in the event that a fire takes place and ensures that correct procedures are followed in the event of an evacuation of the home. On the day of the inspection the quality assurance documentation could not be made available to demonstrate that peoples views are listened to and influence the running of the home. The records in the home must be properly organised and completed to enable ease of access to information as required. The current manager is leaving and a new manager has been appointed. There is no deputy manager in post and the home is lacking a sense of direction. Staffing level need to be reviewed, as on occasions there are only two staff on shift which impacts on the effective running of the home. Staff have expressed concerns in relation to the long hours that they are working and the demands placed on them is affecting the staffs morale. Staff are not all receiving regular supervision, which does not help the service to function effectively and work together in a consistent way. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 1 3 X 4 1 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 1 X 2 3 X Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 26 Yes 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 YA1 Regulation 4 Timescale for action The Registered Person must 15/08/07 ensure that the homes statement of purpose is fully updated. The Registered Person must 15/06/07 ensure that written documentation is available in relation to a full assessment that must be undertaken before a person moves into the home. Also written documentation must be available regarding tea visits and overnight stays. The Registered Person must 10/07/07 ensure that care plans contain the actions agreed at review meetings. The Care plans must be are detailed and fully completed and kept up to date to ensure a persons changing needs are reflected in their plan. This requirement has been restated from the last two inspections previous timescales of 01/07/06 and 12/12/06 was not met. The Registered Person must 20/06/07 ensure that each person is offered individual sessions with their key worker as stated in DS0000010655.V333457.R01.S.doc Version 5.2 Page 27 Requirement 2. YA2 14 (a) (b) 3. YA6 15 (1) (2) (c) 4. YA6 15 (2) Devon House 5. YA9 15 2(a) their care plan and these are recorded in people’s case notes. This requirement is restated from the previous timescale of 24/11/06 was not met. The Registered Person must 15/06/07 ensure that the identified person’s risk assessment includes in sufficient detail how hazards to a persons safety will be minimised this must cover smoking in bedrooms, prevention of the use of the toaster to light cigarettes placing lighted cigarettes above bedroom plug sockets. This must be reviewed monthly and amended if changes occur. The Registered Person must ensure that an easy chair is obtained for the identified persons bedroom. The Registered Person must ensure that the water leak in the ground floor bathroom is investigated and the pipes that have been uncovered are recovered up. The Registered Person must ensure that excessive items that were in room twenty- five do not build up to an excessive amount again. The Registered Person must ensure that room six is redecorated and the carpet is replaced. The Registered Person must ensure the ventilation in the walk in shower room is improved. This requirement has been partly met and has been amended from the previous inspection timescale of 24/11/06 was not met. The Registered Person must ensure that the flooring in the DS0000010655.V333457.R01.S.doc 6. YA24 23 2 (b) 10/07/07 7. YA27 23 2 (b) 10/08/07 8. YA24 16 (2) (c) 01/09/07 9. YA24 23 2 (d) 10/08/07 10. YA27 23 2 (b) 10/08/07 11. YA27 23 2 (b) 25/08/07 Devon House Version 5.2 Page 28 12. 13. YA30 16 2 (j) 18 1 (a) YA33 14. YA35 18 1 (c) 15. YA36 18 (2) ensuite bathroom in room twenty-six is replaced. The registered Person must ensure that the hall carpet is professionally cleaned. The Registered Person must review staffing levels in the home to ensure that the needs of people as identified in their individual care plan are met. The Commission For Social Care Inspection must be informed of the outcome in writing. This was an immediate requirement made at the previous inspection 23/11/06. The Registered Person must ensure that all new staff completes their inductiontraining programme. The Registered Person must ensure that staff receive regular supervision at least six times per year. 15/07/07 15/07/07 10/08/07 20/06/07 16. YA33 8 (2) The Registered Person must 20/08/07 ensure they appoint a deputy manager and recruit to all vacant posts and the Commission For Social Care Inspection must be informed in writing when this takes place. The Registered Person must 20/06/07 ensure that all the records in the home are properly organised and completed to enable ease of access to information as required. This requirement is restated from the previous inspection previous timescale of 24/11/06 was not met. The Registered Person must 20/08/07 ensure that a quality assurance exercise is implemented that seeks the views of people living in the home their relatives and DS0000010655.V333457.R01.S.doc Version 5.2 Page 29 17. YA41 17 ( 3) 18. YA39 24 (1)(3) Devon House other care professionals. 19. YA41 13 (4) The Registered Person must 20/06/07 ensure that the half hourly room checks are undertaken by staff and are clearly recorded and available for inspection. 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 YA11 Good Practice Recommendations The Registered Person must ensure that people have access to a vehicle when they wish to attend planned trips out. Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Devon House DS0000010655.V333457.R01.S.doc Version 5.2 Page 31 - 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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