Inspection on 22/04/08 for Devon House

This inspection was carried out on 22nd April 2008.

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 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 16 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 07/11/07

Devon House 21/05/07

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 Unannounced Inspection 22nd April 2008 11:00 Devon House DS0000010655.V362392.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.V362392.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.V362392.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 Ltd Joseph Clement Mooken Care Home 14 Category(ies) of Dementia (1), Mental disorder, excluding registration, with number learning disability or dementia (14) of places Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC. to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE (maximum number of places:1) (of the following gender: Female). Mental Disorder, excluding learning disability or dementia - Code MD (maximum number of places: 14). The maximum number of service users who can be accommodated is: 14. 7th November 2007 2. Date of last inspection 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 who live in the home. There is a large garden to the rear of the property. The home aims to ensure people are supported to live as independently as possible. The organisations base fee is £780.00. The home has the Purpose and Function Document and Inspection Report on their notice board for interested parties to view. The inspection report can also be viewed on the CSCI website. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is (1 star) this means the people who use the service receive adequate outcomes. This was an unannounced inspection and took place as part of the inspection process. Compliance was checked against key standards and took approximately 7 hours. I undertook a tour of the building spoke with the people who live in the home and members of the staff team. I gained further information from the Annual Quality Assessment form, by an inspection of the documents kept in the home, including care plans and health and safety documentation. The manager and deputy manager offered their assistance throughout the period of the inspection. I would like to thank the people who use the service and the manager and staff team for their openness and participation. What the service does well: What has improved since the last inspection? The manager has now been appointed as the registered manager of the home. This should ensure the home is managed more effectively. The life skills coach is now in post. This assists to improve the quality of care provided in the home. Risk assessments are more detailed which ensures that the risks to the people living and working in the home are minimised. This promotes people’s health and wellbeing. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 6 There is a clear record of relative’s visits. This means that evidence is being recorded to indicate people in the home are being supported to ensure their emotional needs are met. Attempts are being made to assist people to access structured activities such as educational opportunities. This enriches people’s lives. One identified persons bedroom has been decorated. This ensures they live in a nicer environment. The two people who expressed concerns that the televisions were not working can now watch television in their bedrooms. This improves their quality of life. All of the fire records were available up-to-date and clearly recorded. This promotes people’s health and safety. What they could do better: The service user guide needs to be updated. This will ensure that people are provided with the most up-to-date information about the home. The care plans have improved a great deal but would improve further if all the specific areas of the care plan contain detailed information. This would ensure people’s needs are fully met. Health care appointment need to be effectively recorded and indicate the outcome of appointments attended. All health care appointments including dental appointments need to take place. This will ensure peoples health and wellbeing is being promoted. Weight charts need to be kept up –to-date. This will ensure that people’s weight monitoring programme is being effectively managed. A copy of the adult protection policy in relation to the relevant placing authorities adult protection procedures need to be obtained. This will ensure that people working in the home are fully informed and able to protect the people living in the home from potential abuse. A number of environmental improvements need to take place. The dishwasher needs to be replaced as it is broken and is not fit for use. The kitchen bin needs to be replaced as the lid is broken and cannot be used to store household waste effectively, which is not in the interests of people’s health and safety. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 7 The loft hatch needs to be securely covering the loft. This will ensure people living in the home are not able to access the loft and be at risk of injury or harm. The staff need a new bed in the staff sleep in room. This will ensure they can sleep comfortably whilst on a sleep in shift. The person in room 26 needs to be provided with an easy chair in their bedroom to ensure they can relax in comfort. A professional person needs to investigate the damp in room twenty-six and the en suite toilet of room six. Both rooms need to be decorated. This will ensure the people living and working in the home can use the rooms. The shower needs to be fully effective. The ventilation in the shower room must be improved by the updating of the ventilation system. This will ensure the environment is well maintained and fit for use. Staff must undertake training in relation to adult protection, the management of violence and aggression and first aid. This will ensure that staff have the skills to meet the needs of the people living in the home. Staff must receive supervision at least six times per year. This will ensure staff work effectively as a team and assist their professional development. Activity records must accurately record how staff have attempted to engage people in an activity when they do not wish to be involved. All records in the home must be well organised and complete. This will ensure they are easy to access informative and available for inspection. The menu of food could be more varied contain less processed foods. This would assist to promote people’s cultural needs and promote a healthy diet. 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.V362392.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.V362392.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, People who use this service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. People do not have all the information they need to make an informed choice about whether the service is suitable for them and their needs. The service is assessing individual people’s aspirations and needs to ensure people’s needs can be met. EVIDENCE: Since the previous inspection there has been one new admission to the home. I looked at the homes statement of purpose, which has been updated, which ensures that accurate information is available in relation to this document about the service for those people who need it. However the service user guide needs to be updated, as it does not contain the up to date information with regard to the current staff team that are working in the home. This does not provide people who are living in the home or may wish to move into the home with accurate information to assist them to know who the people are who will be supporting them with regard to their care. An Individual assessment had been completed by the homes manager to cover aspects of the individual’s needs, which ensures the peoples specific needs can be met. The manager had also obtained the transfer summary from the previous provider along with the risk checklist, care plan and review document, which further assists to ensure an accurate assessment, is completed. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 10 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, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. The care plans need to obtain all of the information in the specific areas to ensure they are fully effective. People do make decisions about their lives, which ensures their rights are respected. People are supported to take risks as part of an independent lifestyle. EVIDENCE: The registered manager is now in post and along with the deputy manager they are in the process of updating the care plans. They have introduced person centred care plans. This ensures that people’s care plans are more specific in relation to their needs. Care plans were inspected and I found they are much more detailed but some need to be fully completed with regard to particular areas. The deputy manager is in the process of ensuring this takes place with the assistance of the staff team. This will ensure that people’s needs can be fully met. One staff member said, “The deputy manager has spent a long time helping me improve the care plans and has been very supportive.” Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 11 Risk assessments are in the process of being reviewed and updated. The risk assessments cover areas including, depression, self-neglect, verbal outbursts and smoking. A number or documents have been updated and are being reviewed. The management team are working hard to ensure that the identified risks are minimised in relation to people’s individual needs. This will safeguard the health and wellbeing of people living and working in the home. Service user meetings are now taking place. This ensures they have the opportunity to express their views and obtain the support they need. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 12 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): 12,13,15,16,17, People who use the service receive a Good outcome in this area. 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. However consistent recording of activities by staff when activities are refused does not take place. Attempts are being made to improve people’s educational opportunities which if successful will assist their development. People’s rights are respected which increases their self-esteem. People are assisted to maintain appropriate relationships, which assists their emotional wellbeing. People’s rights are respected which makes them feel valued. People’s diets and the variety of food available does not fully benefit their health and wellbeing. EVIDENCE: At Devon House a new life skills coach has been appointed who works twenty hours over a three-day period. The life skills coach and staff team are attempting to develop the activities that are being undertaken. The staff team have made applications to college to include the opportunity for people to expand their educational opportunities by attending life skills and Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 13 independence courses. This will expand people’s educational opportunities if the staff teams attempts to assist people to attend college are successful. This achievement would be a very big step forward for this service. People’s activity records still need to be more accurately recorded to show how staff have attempted to engage people in an activity when it has been refused. There is still a tendency to just record refused on the document without any other detailed information being recorded. This does not ensure that an accurate system for recording people’s information is in place. The activity folder was not organised. It took a great deal of time to obtain the information that I was looking for. The manager of the home acknowledged this and has said he would act to resolve this problem. The area manager has also been informed of this situation. There were clear examples of activities that were undertaken for example, going to the park, shopping in Enfield, going swimming, watching movies at home, attending a party at another home within the organisation. One person had previously gone to the sea- side with a friend. One person attends the community centre and takes part in art, craft, and yoga and is actively involved in the church which ensures their spiritual needs are met. This provides people with the opportunity for social interaction and improves their quality of life. All of the people spoken with were happy with the activities provided. One person said, “I like going to their art and craft sessions and to church.” The manager confirmed that the home does not have its own vehicle that could be used to encourage people to attend day trips and outings. The deputy manager confirmed that all of the people in the home (accept two people who are currently having their passes renewed) have a freedom pass, which assists their independence and promotes their self-esteem. A number of people living in the home receive regular visits from their relatives, which, benefits their emotional wellbeing. There is now a record in place to ensure that an up –to-date record of visits is maintained. This is recorded and kept by the deputy manager. I have expressed the fact that the whole staff team needs to take an active role in ensuring the task is completed. People have keys to their bedrooms which some of the people living in the home use, which assists to ensure their privacy is respected. On the day of the inspection the kitchen was clean and tidy. The fridge and freezer was inspected and food stored in the fridge was labelled appropriately. Fridge temperatures were being recorded. 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 adequate. The food is ordered on the Internet and Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 14 delivered to the home. However the food available needs to be more varied and reflect the cultural needs of all of the people living in the home. This will ensure people’s individual dietary needs and choices are met. Devon House DS0000010655.V362392.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, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. People receive personal care in a way they prefer and require, which ensures their individual rights and choices are respected. People’s physical and emotional health care needs are not being met due to ineffective recording. The process for recording and administering medication is effective which promotes good health. EVIDENCE: The record of people’s health care appointments for each person was inspected. They indicated that people are not being supported to receive all of their individual healthcare checks. This does not ensure that people’s health is being fully monitored. Information is not always effectively recorded on the health record but was identified on the daily recording sheet or noted in the diary. One person had a dental appointment logged in the diary but not on the heath care record or daily log. Staff could not confirm if the person had attended this dental appointment. A consistent process with regard to the recording of information is not being used. People’s health action plans need to be fully up-to-date including the date to indicate when they are reviewed to Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 16 ensure that up-to-date information is available to those people working in the home. The record of people’s weight charts were not all up- to-date. This means their weight-monitoring programme is not being effectively followed. This does not benefit people’s health and wellbeing. Peoples preferences in relation to how they wish their personal care to be provided is being highlighted in their individual care plans. This means their personal wishes are being respected. The medication and administration records were inspected and all medication had been signed for on the medication administration record. This means that professional procedures are being followed. The medication cupboard was inspected and found to be in order. This safeguards people’s health and wellbeing. There are guidelines in place with regard to the administration of PRN medication. There is an up-to-date list on the medication file to indicate the staff that have undertaken training and can administer medication, which promotes good practice. People were appropriately dressed at the time of the inspection. I saw a clear improvement with regard to people’s appearance, which improves their selfimage and quality of life. One staff member I spoke with said, “the people living at the home are clean well dressed the standards of personal care have improved”. Devon House DS0000010655.V362392.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, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. People are not fully protected from abuse neglect and self-harm as all of the required guidance with regard to the placing authorities adult protection policy and procedures are not available to the staff team. EVIDENCE: I examined the complaints book and no complaints had been made since the previous inspection. People living in the home have the complaints procedure in their bedrooms. At the previous inspection the manager agreed to ensure that a copy of the up-to-date complaints policy was given to all of the people living in the home and obtain a copy of their signature to confirm this had taken place. This was then going to be available in people’s individual files. The manager has agreed to ensure this task is completed to ensure people are fully informed of the complaints procedure. This will ensure their rights are respected. The organisations whistle blowing policy was seen and found to be in order. This ensures that people have the necessary information to report any concerns in relation to professional practice within the home. This will benefit the wellbeing of the people living and working in the home. There was no evidence of advocacy contacts or related information being available for the people living in the home, which would benefit them if they wanted to make a complaint. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 18 The adult protection guidelines for the organisation were available however they are due to be reviewed. The adult protection procedures in relation to the relevant placing authorities were not made available at this inspection. This was also identified at the last inspection. I was sent a letter after the previous inspection from the manager confirming the documents had been obtained and were available to staff. I was concerned this documents could not be located for a second time and need to be located and maintained in an identified place. This will ensure staff have all the information they need to ensure people are protected from potential abuse. I have seen evidence that the area manager has written to obtain the necessary documents and have been assured by her that the documents were obtained and she will discuss this issue further with the manager. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 19 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, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. People are not living in a homely, clean, safe environment, which does not benefit their health and wellbeing. EVIDENCE: Devon House is located in a residential area near to local shops and public transport. I completed a tour of the home with the assistance of the deputy manager. I inspected people’s bedrooms and the premises having sought people’s permission. The hall carpet has been cleaned and is more hygienic which benefits the health and wellbeing of the people living in the home. The manager agreed that an ongoing programme with regard to the cleaning of the carpet needs to take place. This will ensure that levels of hygiene within the home are maintained. The person identified in his/her bedroom has continued to manage to limit the number of items that were stored in his bedroom. This means they no longer Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 20 pose a potential fire risk, which promotes the health and safety of people living and working in the home. One identified person has had their bedroom decorated, which ensures they have a nice bedroom to sleep in. Two people have had their televisions fixed and can now watch television in their bedrooms. This improves their quality of life. At the time of the inspection the identified shower room on the top floor had the fixtures and fittings in relation to the shower in pieces on the floor of the shower cubicle. This was an issue that was identified at the previous inspection. This shower room has frequently been affected by mould due to poor ventilation. I clarified at the last inspection that the previous manager had not fitted a new extractor to improve ventilation in the shower room. I had been informed that she had identified an extractor and it would be fitted. At the previous inspection I asked that the ventilation be improved by ensuring that a new ventilation system was fitted. This issue has been raised with the area manager of the organisation. I contacted the manager of the service whilst writing the report and he has confirmed a new ventilation system has been fitted and the shower room has been decorated. I have also contacted the area manager who has confirmed this is the case. I was informed at the last inspection that new tables and chairs had been ordered for the lounge area. These had not been obtained at the time of this inspection. The manager is waiting for them to be approved. I was informed by the manager and area manager that these items have now been ordered. Bedroom six en suite toilet was showing the initial signs of damp at the last inspection. I requested at this time that appropriate action was taken to resolve the issue and ensure the persons health and safety is safeguarded. This en-suite toilet had not had the appropriate action taken at the time of the inspection to ensure the person’s health and wellbeing was promoted and protected. The area was still damp and in need of the appropriate action to be taken and the room needed to be decorated. There is also identified damp in bedroom twenty-four, which also needs action taken with regard to the damp to safeguard the person’s health and wellbeing. I requested a date when this work was due to commence from the manager and area manager. I have been informed the work will begin on the 12/05/08. The dish- washer in the kitchen is broken and needs to be replaced to ensure that all the equipment in the home is working effectively and is fit for use. The manager informed me after the inspection this item has been ordered. The kitchen bin has no lid on the top of it to ensure waste is stored appropriately. This bin needs to be replaced. To store household waste in this way is not hygienic and does not safeguard people’s health and well -being. I Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 21 was informed after the inspection by the manager that a new bin has been bought. The loft hatch cover, which was missing at the last inspection, was still incorrectly fitted leaving a large gap. This does not promote people’s health and safety. The staff sleep in bedroom needs a new bed to be obtained to ensure they have a comfortable bed to sleep in whilst on sleep-in duty. The manager informed me after the inspection that the bed has been ordered. The person living in bedroom 26 is currently using a garden chair to sit on. This does not ensure they can sit in their bedroom in comfort. The manager informed me after the inspection that an easy chair has been ordered. Due to the fact that I have been provided with dates when the necessary work will commence in the home. I have decided to rate the environment as adequate. However given that the lifestyle for people living in the home is being made worse by outstanding maintenance tasks if the same concern exits in future the commission will consider taking enforcement action. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 22 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): 32,34,35,36, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. Not all of the people living in the home are supported by qualified staff which means peoples needs cannot be fully met. People are safeguarded by the homes recruitment policies and procedures. Not all staff are receiving regular supervision so a consistent approach to work with people living in the home cannot be maintained. EVIDENCE: The new manager has now completed the registration process and is the registered manager for the service. This assists to ensure the home is run more effectively. The staff rota was inspected and there were adequate numbers of staff on shift to meet the needs of the people living in the home. The life skills coach has now been appointed. This should improve the consistency of care provided to people living in the home. Staff have now finished their NVQ level 2 and some staff have completed their NVQ level 3. This means that staff are better trained to meet the needs of the people living in the home. Some of the certificates are not available in the staff Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 23 folder and the manager has agreed to obtain these so they are available for inspection. Staff did verbally confirm they had completed their training. One identified staff member who works the night shift has not undertaken all of the statutory staff training such as adult protection training, how to manage violence and aggression and first aid training. Another member of staff had not undertaken up to date adult protection training. This means that these people are not qualified to fully meet the needs of the people living in the home. The staff recruitment policies and all the relevant documentation was inspected and were found to be in order. This protects the people living in the home from potential abuse. Staff supervision is not taking place for all staff as the deputy manager has missed one supervision session. This means that she is not being supported to work with people living in the home in the most consistent way. The issue was discussed with the manager and area manager of the service who insured that a supervision session took place on the same day she was informed of the issue. This concern was also discussed at the time of the previous inspection with the manager. The manager of the home must ensure that the records in the home are organised and fully completed. This will ensure easy access to information as required. This issue was also discussed with the area manager after the inspection and raised at the time of the previous inspection. Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 24 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): 37,39,41,42, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. A registered manager is now in post. This means the home can be managed in a more effective way. The new manager is beginning a process to ensure that people’s views underpin all self-monitoring review and development within the home. The health and safety of the people living in the home is not fully promoted and protected due to outstanding environmental improvements. EVIDENCE: The manager of the service has now completed the registration process and is the registered manager of the home. This means the manager has the skills to ensure the home is run effectively. The newly appointed manager is in the process of sending out documentation to the people who live in the home, their relatives and relevant professionals to Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 25 ensure that people’s views development in the home. underpin all self-monitoring review and I looked at the provider visits on the day of the inspection and the organisations area manager had noted some of the areas I had identified. However action had not been completed within the allocated timescales. This is not an example of good practice. I am also being sent regulation 37 notifications of incident forms. I inspected a range of health and safety documentation. Fire drills had taken place. The weekly bell tests were complete, regular fire door checks were taking place to ensure the fire doors were working effectively. The fire alarm system had been inspected to ensure it was operating appropriately. The emergency lighting had been checked regularly. The gas, electric and portable appliance certificate were seen and found to be in order. The liability insurance certificate was seen and found to be in order. This means that people’s health and safety is protected in relation to these identified areas. However the health safety and welfare of people living in the home is not fully promoted and protected. This is due to two bedrooms and a bathroom being affected by damp. This does not promote the health and wellbeing of the people living in the home. The area manager was contacted on the day of the inspection and again at the time of the report was being completed. I was informed that approval had been given for the work to commence. The work will begin on the 12/05/08. (Please also refer to the section headed environment.) Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 26 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X 2 X X Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 27 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 27/07/08 ensure that the service user guide is up-dated. This will ensure that all information is accurate. People using the document will then be provided with the most up to date information regarding the service. The Registered Person must 01/07/08 ensure that all the specific areas of the care plans contain detailed information and are kept up to date. This will ensure that people’s individual needs are fully met. The Registered Person must 12/06/08 ensure that all health care appointments are undertaken. This must include dental appointments. All appointments must be effectively recorded with outcomes. This will ensure that people’s health care needs are fully met. This requirement has been restated. The previous timescale of 12/01/08 was not met. DS0000010655.V362392.R01.S.doc Version 5.2 Page 28 Requirement 2. YA6 15 (1) (2) (c) 3. YA19 12 Devon House 4. YA19 12 5. YA22 22 The Registered Person must 10/06/08 ensure that people’s weight charts are kept up-to-date. This will ensure that people’s weight is being effectively monitored and their health and wellbeing is being promoted. The Registered Person must 20/05/08 ensure that a copy of the Adult protection policy in relation to the relevant placing authorities adult protection policy and procedures are obtained. This will ensure that people working in the home are fully informed and able to protect people from potential abuse. The Registered Person must ensure that the dishwasher is replaced. This will ensure that the people living and working in the home are using equipment that is working effectively and promote their health and safety. The Registered Person must ensure that the kitchen bin is replaced. This will ensure it is working effectively and household waste can be stored appropriately. The Registered Person must ensure that the loft hatch is replaced and is secure. This will ensure that people are living in a safe environment. This requirement has been restated from the previous inspection. The previous timescale of 10/12/07 was not met. The Registered Person must ensure that a new bed is obtained for use in the staff sleep in room. This will ensure that staff are provided with a comfortable bed to sleep-in DS0000010655.V362392.R01.S.doc 6. YA24 23 (2) (c) 20/05/08 7. YA24 23 (2) (c) 17/05/08 8. YA24 23 (2) (b) 17/05/08 9. YA24 23 (2) (c 20/05/08 Devon House Version 5.2 Page 29 when they are on sleep –in duty. 10. YA24 23 (2)(c) The Registered Person must 20/05/08 ensure that the person in room 26 is provided with a comfortable easy chair in their bedroom. This will ensure they can sit in their bedroom in comfort. The Registered Person must 28/06/08 ensure that an appropriate professional person investigates the person’s bedroom in room 26 that has damp on the walls. Appropriate action must be taken to resolve the problem. The bedroom must then be redecorated to ensure the person is living in a pleasant environment. The Registered Person must 17/05/08 ensure the shower is fully effective. The ventilation in the shower room must be improved by the updating of the vent. This will ensure the environment is maintained and fit for use by the people who live there. This requirement has been restated. The previous timescales of 21/05/07 and 01/01/08 were not met. The Registered Person must 28/06/08 ensure that the person’s toilet in room six that appears to be showing signs of damp on the walls is investigated by an appropriate professional. Appropriate action must be taken to resolve the problem. This toilet must then be redecorated so that the environment is well maintained. This requirement has been restated. The previous timescale of 20/12/07 was not met. DS0000010655.V362392.R01.S.doc Version 5.2 Page 30 11. YA24 23 (2) (b) 12. YA27 23 (b) 13. YA27 23 Devon House 14. YA35 23 15. YA36 18 (2) The Registered Person must 20/07/08 ensure that staff undertake training in relation to adult protection, management of violence and aggression and first aid. This will ensure staff have the necessary training to meet the needs of the people living in the home. The Registered Person must 17/05/08 ensure that all staff receive supervision at least six times per year. This will ensure that staff work effectively as a staff team. This requirement has been restated, as the previous timescale of the 20/06/07 and 10/01/08 has not been met. The Registered Person must 20/06/08 ensure that people’s activity records are more accurately recorded to show how staff have attempted to engage people in an activity when it is refused. This requirement has been restated. The previous timescale of 15/01/08 was not met. 16. YA41 16 Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 31 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 YA17 Good Practice Recommendations The menu of food available must be more varied and ensure it meets people’s individual cultural needs. I strongly recommend that all records in the home are properly organised to ensure ease of access to records as required. 2 YA41 Devon House DS0000010655.V362392.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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.V362392.R01.S.doc Version 5.2 Page 33 - 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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