Inspection on 22/09/05 for Devon House

This inspection was carried out on 22nd September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 9 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 21/05/07

Devon House 05/05/06

Devon House 24/02/06

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 22 September 2005 09:00 Devon House DS0000010655.V249376.R01.S.doc Version 5.0 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.V249376.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V249376.R01.S.doc Version 5.0 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) Parkcare Homes (No. 2) Limited Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2004 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 service users and a garden to the rear of the property. The home aims to ensure service users are supported to live as independently as possible. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection process. The inspector also sought to confirm that the ten areas for improvement found at the last inspection were addressed. The inspection took place over one day. The registered manager assisted the inspector. The inspector spoke with four people who live at the home, and four staff. The inspector toured the building and examined a range of records relating to the care and management of the home. What the service does well: What has improved since the last inspection? 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 Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 6 contacting your local CSCI office. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 7 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.V249376.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users needs are assessed prior to admission to the home. The home does not meet all the assessed needs of service users. EVIDENCE: Since the last inspection an assessment format has been prepared which covers the mental health needs of service users. This was an outcome-based assessment and is focused on mental health needs. The inspector saw an example of this used for a new service user who is to be admitted to the home shortly and found that it enables needs to be clearly identified. There were also assessments from other professionals. Service users spoken to felt that staff understood their needs. Care plans detailed the action to be taken to meet the needs of service users. The manager explained that one service user who has been diagnosed with dementia has needs that the home is not able to meet. The home had already informed the Commission that they were not able to meet this service user’s needs. The inspector discussed this with the manager and it was agreed that a multi-disciplinary review be carried out to ensure that the service user receives the care they need. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 69 Care plans do not provide detailed information on how the needs of service users would be met. Risks to the service users were assessed. EVIDENCE: Service users said that staff do not understand all their needs. Service users explained that staff do not always know how to respond when they express their feelings. Care plans were found to contain general information on the needs of service users but, as the manager agreed, were general and needed information on the individual mental health needs of service users and how they should be supported. The manager explained that many of the staff were new to working with people with mental health needs and she needed to share information on the service users with them. The inspector observed that service users were supported to live independently. Service users went to the shops and for a walk to cash a pension. Risk assessments were seen to be in place that outlined the risks to service users. Staff spoken to generally understood the risks to service users. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The Service users are provided with a choice of varied and balanced meals. EVIDENCE: Service users said that they had chosen the food. Service users explained that they were offered a varied diet. The menu showed that nutritionally balanced meals were offered. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 Service users medical needs are being met. Service users are protected by safe procedures for handling medication. EVIDENCE: Service users confirmed that they had access to appropriate medical support. Records showed that medical attention had been provided. The manager explained that professional support had been sought with regard to service users’ mental health needs. The inspector found that the records of medicines received, administered and returned to the pharmacist were all complete. Records showed that medication is stored at below 25°C. All staff have now received training on the home’s medication policy. A metal cabinet has been purchased for the safe storage of medicines. Reviews of service users medication had been carried out. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Service users said that they felt confident in making their concerns known to staff. The complaints policy explained how to make a complaint and how it would be dealt with. The complaints record showed actions taken to resolve complaints. Service users said that they felt safe and could approach staff if they had any concerns regarding how they are treated. There were comprehensive policies on handling abuse and protection. Staff spoken to were clear about the signs of abuse and how suspected abuse should be handled. Records showed that staff had received training on adult protection. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 Carpets need to be replaced to ensure that the home provides a safe and comfortable environment. The home provides a clean and hygienic environment for service users. EVIDENCE: The manager explained that the premises are being redecorated and a new floor and shower are being fitted. The inspector found that the carpet in bedroom 22 was dirty and worn and this will need to be replaced. The hallway carpet also needed replacing, as it was very worn. Quotes for a new kitchen had been obtained and it was to be redecorated and refurbished. The inspector found that the home was clean and hygienic. Staff spoken to understood how to prevent cross infection and equipment was provided for this purpose. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 34 35 36 Staff do not have all the skills to meet the needs of service users. The home does not have sufficient staff to meet the needs of the service users. Service users are protected by the home’s recruitment procedures. Staff are not appropriately supervised thus putting service users at risk. EVIDENCE: Although the staffing level was maintained. The inspector spoke with two staff who explained that they were on long days. The rota showed this had been happening every day. The inspector spoke with the manager who said this was due to the need to recruit staff. Some work has already been done towards this, but this needs to be completed in order that enough staff are available. Staff files were found to contain all the necessary documentation on the recruitment of staff. Records showed that all staff are doing the National Vocational Qualification in care and two staff have already completed the award. The home still needs to achieve the target of 50 of staff having this qualification. Staff spoken to said that they had not had training on mental health and could not explain some of the common features of mental illness. This was discussed with the manager who explained that two courses had been provided but not all staff had been on them. Records confirmed that staff had had the required statutory training. A supervision system was introduced by the company and had a business objectives focus. The inspector found that this meant that it was not related to the work done by care staff and the Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 15 manager explained that there were difficulties in using it for this purpose. Also, records showed that not all staff had received supervision regularly. As a result of this, staff had not received the necessary support to ensure that they could support service users. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41 42 Records are maintained to ensure the safety of service users. Service users and staff health and safety is promoted. EVIDENCE: The inspector found that all the records examined were clearly written and contained the necessary information. The inspector found that staff had training on health and safety topics. The hoists had been checked and all first aid boxes had the necessary items. Fire procedures and a risk assessment were in place. The inspector found that the fire risk assessment had not been reviewed since 2002. The inspector examined the home’s records and found that the alarm system had been inspected and checked regularly. Fire drills had occurred regularly and were recorded. The training records showed that staff had received training on fire prevention. The necessary records of food temperatures and of the fridge and freezers had been maintained. Gas and electrical certificates were seen and in date. Testing had taken place for Legionella. Since the last inspection a risk assessment had been carried out and all the radiators had been covered to prevent service users touching hot surfaces. The home had all the necessary policies and procedures in place to ensure the safety of service users and staff. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 3 x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 2 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Devon House Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x X X X 3 2 X DS0000010655.V249376.R01.S.doc Version 5.0 Page 18 N0 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 YA2 Regulation 14 Requirement The registered persons must ensure that a multi-disciplinary review is carried out for a service user with dementia to determine how their needs can be met. The registered persons must ensure that care plans contain detailed information on how the needs of service users must be met. The registered persons must ensure that the carpet in bedroom 22 is replaced. The registered persons must ensure that the carpet in the hallway is replaced. The registered persons must ensure that staff are recruited for the home. The registered persons must ensure that staff have training on mental health. The registered persons must ensure that a system of supervision is in place that supports care workers in their work. The registered persons must ensure that staff receive supervision six times a year. DS0000010655.V249376.R01.S.doc Timescale for action 01/11/05 2 YA6 15(1) 01/12/05 3 4 5 6 7 YA24 YA24 YA33 YA35 YA36 16(2)C 16(2)c 18(1)(a) 18(1)(a) 18(2) 01/01/06 01/01/06 01/12/05 01/01/06 01/01/06 8 YA36 18(2) 01/12/05 Devon House Version 5.0 Page 19 9 YA42 23(4)(a) The registered persons must ensure that the fire risk assessment is reviewed. 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA35 Good Practice Recommendations The registered persons should ensure that 50 of staff achieve the NVQ at level two in care by 31/12/05. Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Devon House DS0000010655.V249376.R01.S.doc Version 5.0 Page 21 - 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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