Inspection on 24/02/06 for Devon House

This inspection was carried out on 24th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17 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 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 24th February 2006 11:45 Devon House DS0000010655.V271060.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.V271060.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.V271060.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) www.craegmoor.co.uk 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.V271060.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd September 2005 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.V271060.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 an annual inspection process. Five areas for improvement at the last inspection were addressed. The inspection took place over one day. The deputy manager assisted the inspector. The inspector spoke with five people who live at the home and two 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: The registered persons must provide the inspector with arrangements for the planned move for the identified service user including the date and time of the proposed move. All key worker records must be kept up to date. All care plans must be updated and signed by service users and their representatives. This requirement has been restated. All risk assessments must be updated and reviewed on a regular basis. Clear guidance must be available and action must be taken in relation to those service users who smoke in their rooms. Risk Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 6 assessments must be put in place in relation to those service users who refuse to attend medical appointments. A record of service users wishes in the event of their death must be recorded. A weight chart must be in place with a medical document that gives typical weights and height this means that any weight loss programme can be recorded to ensure the service users do not fall below their healthy weight. The manager must ensure that action taken to resolve complaints are signed and dated to show they are completed within timescale. All staff must have access to assessors to complete their NVQ. Staff must receive training in relation to mental illness. This requirement is restated. The outstanding action in relation to the fire risk assessment must be completed. The London Fire and Emergency Planning Authority must be consulted when the action outstanding from the fire risk assessment has been completed. The manager must ensure they are registered with The Commission for Social Care Inspection. Requirements have been made in relation to all of the above. The shower on the first floor must be in good working order and kept clean. The carpets in the bedrooms and hallway must be replaced. Immediate requirements have been made in relation to these. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the timescale will lead to the Commission for Social care inspection considering enforcement action to secure compliance. 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. Devon House DS0000010655.V271060.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.V271060.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): 2,3 The home does not meet all the assessed needs of service users. EVIDENCE: A number of service user files were inspected. An assessment format is in place, which covers the mental health needs of service users. These assessment formats are being used for the new service users who had been admitted to the home and service users needs are clearly identified. One of the service users who had been diagnosed with dementia has needs the home is not able to meet. At the last inspection it was agreed that a multidisciplinary review would be carried out to ensure that the service user receives the care they need. This requirement has not been met. The inspector has been informed that funding has now been agreed to provide the service user with a more suitable placement. The inspector would like to be provided with the arrangements that are going to be put in place including a date and time for the planned move. A requirement has been made in relation to this. The deputy manager showed a good understanding of the individual service users needs and could talk in detail in relation to their role. Devon House DS0000010655.V271060.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): 6,8,9 Care plans do not provide detailed information on how the needs of service users would be met. Risk assessments are not all updated so do not ensure the safety of service users. EVIDENCE: Service users case notes were inspected. Each service user has a named linked worker. All of the key worker recordings are not all kept up-to date. Some care plans had been updated. All service users care plans must be updated and reviewed on a regular basis. The care plans must be signed by service users or their representatives. All risk assessments must be updated and the document must be available to evidence the evaluation of risk that has taken place. Clear guidance must be available in relation to those service users who are currently smoking in their bedrooms and action must be taken in relation to this. Requirements have been made in relation to all of the above. The inspector independently. Devon House observed that service users were supported to live DS0000010655.V271060.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): 12,15,16,17 Service users are provided with a choice of varied and balanced meals. Service users have appropriate personal family relationships. EVIDENCE: Service users are able to take part in age, peer and culturally appropriate activities such as attending church. On the day of the inspection five service users spoke with the inspector on both a one-to-one basis and in a group situation. Service users discussed their daily activities and family contact. Service users contact varies ranging from personal visits to telephone calls. On the day of the inspection the kitchen was clean and tidy. The inspector noted that food stored in the fridge had been correctly labelled and was in date order. A menu book is kept which shows service users choice of different meals. The menu showed that nutritionally balanced meals were offered. Service users benefit from a mixed staff team who bring a range of different ideas to the home in terms of food preparation. This means that service users have access to different types of foods than they may otherwise experience. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 11 Staff interacted appropriately with service users and there was a warm and friendly atmosphere in the home. Service users privacy was respected. Service users have keys to their rooms and on in day of the inspections service users that were out and had locked their doors had this right respected. The inspector was informed that staff would not enter their room in this situation unless a heath and safety risk was identified. The inspector was concerned that a number of service users smoke in their rooms, which is against their identified guidelines. There was evidence of severe burns on the carpets and bedroom bins, as a result of cigarettes or cigarette ash being dropped. The Deputy Manager has agreed in consultation with the manager of the home that service users privacy will have to be overridden to ensure that service users do not smoke in their rooms. This will ensure their safety is guaranteed in relation to the risk of fire. The manager will have to ensure that service users infringement of rights forms are completed in relation to this area of health and safety and if there is a need to enter service users bedrooms. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 12 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): 19,20,21 Service users are protected by safe procedures for handling medication. Service users medical needs are not met as risk assessments are completed. Service users wishes in the event of their death are not recorded to ensure their wishes are respected. EVIDENCE: The record of medical appointments for each service user was inspected. Some service users are being supported to receive their individual medical checks. The inspector found it difficult to identify what checks had taken place and the reason for the appointment being booked. When residents refuse medical checks they must have an appropriate risk assessment in place. The case notes inspected did not include a record of the service users and their relative’s wishes in the event of their death. Requirements have been made in relation to the above. The medication records were inspected and found to be in good order. Medication is signed for and recorded on the medication administration record sheets. The medication Cabinet was inspected and all medication and medication doses were found to be in order. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 13 The inspector looked at the weight chart of service users. The inspector noted that there is not a record in relation to the weight chart that suggests there is a weight programme in operation that gives the typical weight of for example a female and what the target weight should be in terms of weight and height. This should be used as a comparison in relation to the expected weight in relation to service users. This means that any weight loss programme can be recorded to ensure the service users do not fall below their healthy weight. A requirement has been made in relation to this. Service users were appropriately addressed at the time of the unannounced inspection. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 14 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 can be confident that their complaints will be listened to. Recording must be improved to ensure that complaints are taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The complaints policy explains how to make a complaint and how it would be dealt with. The complaints record showed actions taken to resolve complaints. The manager must ensure there where a complaint is made the actions taken are signed and dated to show that they are completed within timescale. If a written response has been provided separately and placed on a service users file then a note of this must be made in the complaints book. There are comprehensive policies on handling abuse and protection. Records showed that staff had received training on adult protection. Service users said they felt safe and could approach staff if they had any concerns regarding how they are treated. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 15 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): 24,27,30 The carpets need to be replaced, as the home does not provide a safe and comfortable environment. The shower is not clean and in working order. The home does not provide a clean and hygienic environment for service users. EVIDENCE: Devon house is in large, detached modern house in a residential area of Oakwood and is in keeping with the surrounding premises. The home provides access to local amenities including shops, parks and public transport. Each service user has a single bedroom and these were appropriately furnished. During the inspection the inspector noted that the shower on the first floor was not in good working order, it was not clean and not fit for use. The inspector noted that the carpet in bedrooms one, four, seven and twenty six had been damaged due to the smoking of cigarettes in bedrooms these carpets must be replaced. At the previous inspection and inspector had made Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 16 a requirement that the hallway carpet must be replaced. This requirement had not been met. Immediate requirements were made in relation to all of the above. Staff spoken to understood how to prevent cross infection and equipment was provided for this purpose. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 17 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): 33,35,36 Staff do not have all of the skills to meet the needs of service users. The home now has sufficient staff to meet the needs of service users. EVIDENCE: Staff files were inspected and contained all the necessary documentation in relation to the recruitment of staff. The staff have not completed their NVQ due to the fact that they have not had have access to assessors. A good practice recommendation was made at the last inspection. A requirement has been made in relation to this at this inspection. Supervision records were inspected and all staff was receiving regular supervision. This was a requirement made by the previous inspection, which has now been met. All staff need an individual staff training record folder that is easily accessible. A good practice recommendation has been made in relation to this. At the previous inspection and staff had not had training on mental health and could not explain some of the common features of mental illness. At the time of the inspection the inspector could not be provided with evidence that this training had taken place. This requirement has been restated. The registered Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 18 manager has recruited staff for the home. This is a requirement made at the last inspection, which has now been met. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 19 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. The fire doors must be fitted as required by the fire risk assessment to ensure the health and safety of service users is met. EVIDENCE: The Inspector found staff had training on health and safety topics. The hoist had been checked. First-aid boxes had the necessary items. Fire procedures were found to be in order. The fire risk assessment had been reviewed. This was a requirement made at the previous inspection that has now been met. The fire doors must all be fitted as required by the fire risk assessment. Requirements have been made in relation to this. The inspector examined the homes records and found that the alarm system had been inspected and checked regularly. Fire drills had occurred regularly and were recorded. Training records showed that staff had received training on fire prevention. Gas and electrical certificates were seen and in date. The manager must improve the system for storing, recording and maintaining records to ensure they are easily accessible and organised. The current manager must ensure Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 20 that they are registered with the Commission for Social Care Inspection. A requirement has been made in relation to this. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 21 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 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 2 X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Devon House Score X 2 3 2 Standard No 37 38 39 40 41 42 43 Score X X X X 2 2 X DS0000010655.V271060.R01.S.doc Version 5.0 Page 22 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 YA2 Regulation 14 Timescale for action The registered persons must 30/03/06 provide the inspector with the arrangements for the planned move of the identified service user including the date and time of the proposed move. The registered persons must 10/04/06 ensure that all care plans have been updated and contain detailed information on how the service users needs are met. The service users and their representatives must sign care plans. This requirement is restated previous timescale was 01/12/05 The registered persons must ensure that all key worker monthly recordings are kept up to date. The registered persons must ensure that all risk assessments are updated. This must include a clear evaluation form. The registered persons must ensure that there is a clear recording system in place in relation to medical appointment. The registered person must DS0000010655.V271060.R01.S.doc Requirement 2. YA6 15 (1)(2) (a) 3. YA41 17 (m) 30/03/06 4. YA9 14 (2) 20/05/06 5. YA9 19 (3) 10/04/06 6. YA9 19 (3) 20/04/06 Page 23 Devon House Version 5.0 7. YA21 12 (4) (b) 8. YA19 12 (1( (a) 9. YA22 22 (4) 10. YA27 23 (c) (d) 11. YA24 16 (2) (c) 12. YA24 16 (2) (c) ensure that when a service user refuses to attend medical appointments a risk assessment is completed. The registered persons must have the wishes of service users and their relatives recorded in the event of their death. The registered persons must ensure there is a weight programme in operation and there must be a medical document that can be referred to as a comparison to indicate what the expected weight should be. The registered persons must ensure that when a complaint is made that her actions are dated and signed to show that action is taken within timescale. If a response is noted on the service users file then a note of this should be made on the complaints book to indicate this. The registered persons must ensure that the shower on the first floor that is not clean and is not in good working order is not used until it is clean and fit for the purpose. Immediate requirement. The registered persons must ensure that the carpets in rooms one, four, seven and twenty six Damaged due to the smoking of cigarettes is replaced. Immediate requirement. The registered persons must ensure that the carpet in the hallway is replaced. Immediate requirement 10/06/06 10/04/06 30/03/06 27/02/06 17/03/06 10/03/06 13. YA35 18 (1) 14. YA35 18 (1) (a) The registered persons must 01/04/06 ensure that staff undertake the NVQ and have consistent access to assessors. The registered persons must 01/04/06 ensure that staff have training DS0000010655.V271060.R01.S.doc Version 5.0 Page 24 Devon House on mental health. This requirement has been restated previous timescale 01/01/06 15. YA42 23 (4) (a) (b) The registered persons must 01/04/06 ensure that the action required from the fire risk assessment is completed. The London Fire and Emergency Planning Authority must be contacted to visit the home to ensure all of the necessary requirements are in place. The current manager must 10/05/06 ensure they are registered with the Commission for Social Care Inspection. Risk assessments regarding the 10/03/06 risk associated with smoking in their bedroom. The risk assessment must be reviewed monthly and amended if changes occur. 16. YA37 8 (2) 17. YA9 14 (b) 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 Staff must have an individual training record. Devon House DS0000010655.V271060.R01.S.doc Version 5.0 Page 25 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.V271060.R01.S.doc Version 5.0 Page 26 - 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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