Inspection on 05/05/06 for Devon House

This inspection was carried out on 5th May 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 14 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 24/02/06

Devon House 22/09/05

Devon House 19/10/04

Devon House 17/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Devon House 49 Bramley Road Oakwood London N14 4HA Lead Inspector Wendy Heal Key Unannounced Inspection 5th May 2006 10:00 Devon House DS0000010655.V289873.R01.S.doc Version 5.1 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.V289873.R01.S.doc Version 5.1 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.V289873.R01.S.doc Version 5.1 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.V289873.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24th February 2006 Brief Description of the Service: Devon House is owned by Parkcare Homes Ltd. Devon House is a large, detached, modern house in a residential area of Oakwood. There are fourteen single bedrooms. All bedrooms have en-suite facilities and are located on two floors. The kitchen and dining room are at the front of the house. There is adequate communal space for the number of 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. The organisations fees range from £692.00 to £715.00. The home has the Purpose and Function Document and Inspection Report on their notice board for interested parties to view. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards and took approximately 6 hours. The inspector undertook a tour of the building and spoke with service users and members of the staff team. The inspector gained further information by an inspection of the documentation kept in the home, including care plans and health and safety documentation. The Manager and Deputy Manager assisted the inspector throughout the day. The inspector would like to thank the service users present during the inspection, the managers, staff and service users for their openness and participation. What the service does well: What has improved since the last inspection? The care plans have been updated and contain detailed information in relation to service users needs, which means staff are more able to ensure their needs are met. The service users risk assessments are now up to date which means that the risk to service users has been minimised. The wishes of service users are now recorded in the event of their death. There is now a weight programme in operation, which supports the health and wellbeing of service users. Complaints are now being recorded appropriately, which means that service users know that complaints are taken seriously and a clear record is maintained. Environmental improvements have been made which provides a more homely environment. Staff are undertaking training in relation to the NVQ. Staff had undergone training in relation to mental health, which means staff are more equipped to meet service users needs. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 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.V289873.R01.S.doc Version 5.1 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): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are given the information they need to make an informed choice about whether the service is suitable for them and their needs. The service is good at assessing individual service users aspirations and needs. The service users have an individual contract of terms and conditions, which assists service users to have an understanding of what they can expect from the organisation. EVIDENCE: Since the previous inspection there has been one new admission to the home. The home has an up to date Purpose and Function Document. The service has a Service User Guide. The home’s Service User Agreement clearly specifies the terms and conditions of the home including details of the notice period. Service user care plans are now being reviewed on a regular basis and are being signed by service users where possible. The care plans need to contain the actions agreed at review meetings to ensure that service users changing needs are met, which will ensure that a consistent approach is adopted by all staff. The manager and staff interviewed showed a good understanding of individual service users needs and they could talk in detail in relation to their role. The service users spoke very positively in relation to staff and the support they receive saying, “they are the best”. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 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): 6,7,8,9,10 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to this service. The service is good at assisting service users to make decisions about their lives. The service is good at supporting service users to take risks to develop an independent lifestyle. Service users are consulted on and participate in all aspects of life in the home. The service must improve the way that service user information is stored to ensure that service user confidentiality is maintained. EVIDENCE: Service user care plans were inspected, they were clear to understand and up to date. The care plans of service users evaluate all aspects of living in the home. The needs are identified as well as the aim to achieve a care intervention and the care plans are being evaluated on a regular basis. The plans specify the areas in which service users make decisions about their lives with assistance. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 10 The risk assessments now show potential risks for service users and are being reviewed; the areas covered include depression, medical appointments, smoking in bedrooms, physical and verbal outbursts and self-neglect. The inspector saw evidence that service users are still smoking in their bedrooms and the new carpets have burn marks on them and there is a continued risk of a potential fire taking place as a consequence of service users smoking whilst in bed. The manager has informed the inspector that she is going to discuss this issue with her area manager and seek advice. Service user meetings are taking place, which ensures service users have the opportunity to express their views. Service users discussed areas such as activities, having a holiday and one service user expressed in the meeting that they would like to go on a bus tour. Service user information needs to be stored more appropriately to ensure that service users confidentiality is respected. The main files are kept in the office on open shelves, which does not guarantee that confidentiality is maintained. A requirement has been made in relation to this. Information stored on the computer is accessed by a password. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 11 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): 12,13,15,16,17 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Service users are supported to develop their skills within the home, which assists their independence. Service users are part of the local community, which enriches their lives. However, clear recording of activities needs to be in place to ensure service users achievements are kept up to date. Service users rights are respected, which emphasises they are valued and increases their self-esteem. Service users are assisted to maintain appropriate relationships, which assists their emotional wellbeing. Service users are supported to choose healthy nutritious meals, which assists service users maintain a healthy lifestyle and promote good health. EVIDENCE: At Devon House service user activity records were inspected. They need to be more accurately recorded and kept up to date to ensure a consistent record is maintained to show the activities that service users undertake and how these enrich service users lives and identify their achievements on a daily basis. A requirement has been made in relation to this. Service users are supported to Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 12 access community based activities, which appear to be linked to their needs and preferences. This was evidenced by discussion with service users and observations on the day of the inspection. Service users undertake day care activities ranging from attending a Drop In Centre and a Homeless Resource Centre. One service user also undertakes voluntary work three days per week. One service user spoken with said, ”I like my activities”. Service users have limited activities available within the home, e.g. bingo. Service users need to have available to them board games and arts and crafts materials to ensure they have access to stimulating activities within the home. A good practice recommendation has been made in relation to this. The service does not have a vehicle available to use in relation to day trips or outings, which would benefit service users and encourage them to take part in a range of activities. The care plans identify how service users are supported to develop their independent living skills, are specific and are kept up to date. This was a requirement made at the previous inspection, which has now been met. Service users contact varies ranging from personal visits to telephone calls. On the day of the inspection a service user’s brother was visiting her and she spoke with the inspector and said, “I am looking forward to seeing my brother”. On the day of the inspection this service user was going shopping with a member of staff and returned home having bought some new clothes, she said she was “very pleased with them” and wore these for her brother’s visit. Service users have a key to their bedroom, which ensures their privacy is respected. There is also acknowledgement of restriction of service users liberty which is recorded in service users risk assessments in relation to staff completing room checks every half an hour in relation to those service users who continue to smoke in their bedrooms which poses a health and safety risk to service users in relation to an increased risk of fire. Staff were aware of service users preferences in relation to meals and negotiated with service users in relation to their menu and diet. One service user explained how they had requested for liver to be removed from the menu. The menu of food available was wholesome and nutritious. The service users dietary needs are being met which benefits their health and wellbeing. On the day of the inspection the kitchen was clean and tidy. The fridges were inspected and open food stored in the fridge was labelled appropriately and items stored were within their use by date. The inspector saw evidence of colour coded chopping boards to prevent cross infection, and the manager is going to obtain colour coded chopping knives now that the inspector has explained their relevance in relation to preventing cross infection. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 13 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 food than they may otherwise experience. The inspector observed the interaction between staff and service users, which was appropriate and the atmosphere was warm and friendly. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 14 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): 18,19,20,21 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to the service. Service users receive personal support in a way they prefer and require, which ensures that individual rights and choices are respected. There is good support provided to service users to access healthcare appointments. The process for administering medication is not effective and does not promote the good health of service users. The wishes of service users in the event of their death are recorded to ensure their wishes are respected. EVIDENCE: Service users all have access to primary and specialist healthcare appointments. Service user care plans and records of medical appointments inspected indicated that service users have access to general practioners, dentists, opticians and other healthcare professionals. The medication cabinets were inspected. The inspector looked at the medication records and on that particular day the responsible person had not signed the medication record, but had administered the medication. The staff had received medication training to ensure that service users are protected by the homes medication procedures. The inspector discussed this area of concern with the staff member responsible, the manager, and deputy manager at the Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 15 time of the inspection, as these actions do not support good practice in relation to safeguarding service users health. A requirement has been made in relation to this. The inspector was shown a record of staff sample signatures. These were in relation to the staff who are authorised to administer medication. The homely medicines book had been kept up to date. The inspector looked at the weight charts of service users and they had been kept up to date. A consistent approach is now in place in relation to the process to support service users with weight management. The manager has confirmed that she is in the process of obtaining a height chart. There are clear records in terms of medical appointments taking place, which ensures service users health needs are met. Service users were appropriately dressed at the time of the inspection. The service users case notes were inspected and included a record of service users wishes in the event of their death, which ensures their individual wishes are respected. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 16 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 Quality in this outcome area is adequate. The judgement has been made from evidence both during and before the visit to the service. Service users can be confident that their views are listened to and acted upon, since the recording of complaints and actions is adequate. Service users are protected by trained staff who had an adequate understanding of how to protect service users from abuse, neglect and self-harm. EVIDENCE: At the time of the unannounced inspection the inspector looked at the complaints file. There are no new complaints since the previous inspection. The manager now ensures that when a complaint is made her actions are dated and signed to show that actions are taken within timescale in accordance with the homes complaints procedure. Where a response is noted on the service user file then a note of this is now made in the complaints book. The company policy on whistle blowing was satisfactory and staff are familiar with how to use it. Staff at the home had attended Adult Abuse and Protection of Vulnerable Adults training and during discussions with them they were knowledgeable with regard to the reporting procedures. Financial records were not inspected on this occasion. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 17 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): 24,25,26,27,29,30 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Improvements to the home have been made and further action is needed to ensure the home is comfortable and homely for all of the service users. Service users bedrooms do not suit all of their needs. Service users have the specialist equipment they require to maximise their independence. The home was clean. EVIDENCE: Devon House is located in a residential area near to local shops and public transport. During the tour of the building the inspector was able to look at the service users bedrooms having sought permission. The service users bedrooms were not all furnished to suit their needs and some new items need to be obtained to ensure their needs are met. The shower on the first floor was clean and in good working order, which ensures that service users health and safety is protected. This was an immediate requirement made at the last inspection, which has now been met. The carpets in rooms one, four, seven, twenty-six which were severely damaged due to service users smoking in their bedrooms, have now been Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 18 replaced which means they have a nicer environment in which to live. This was an immediate requirement made at the last inspection, which has now been met. One service user said he “liked the new carpet in his room”. The carpet in the hallway has now been replaced, which ensures that this area is now clean and promotes the health, safety and wellbeing of staff and service users. This was an immediate requirement at the last inspection, which has now been met. The identified service user in room twenty-three needs a new mattress to ensure he can sleep in adequate safety and comfort. This service user also requires his wardrobe door to be replaced or a new wardrobe to be obtained, to ensure that the equipment provided in his bedroom is fit for use. The identified service user in room twenty-six needs his room to be decorated. The identified service user in room twenty-five must have his room decorated and the carpet replaced and the excessive items stored in this room removed, due to the serious health and safety risk this currently presents. The service user in room six must have their carpet replaced. Requirements were made in relation to all of the above. The manager informed the inspector that the dining room floor is due to be replaced in the next week, which will enhance the service users eating area. The Manager informed the inspector that the kitchen on the ground floor is going to be redecorated as it is starting to appear dirty and does not improve the homely environment for service users. The kitchen cupboard doors need to be updated and the kitchen floor needs to be replaced or sealed to ensure that the needs of service users in terms of their health and safety are met. A requirement has been made in relation to this. The mixer valves throughout the home need to be replaced to ensure that service users are provided with consistent hot water and they are protected from being scalded. A requirement has been made in relation to this. Service users need to be provided with garden furniture and umbrellas to ensure that they have the opportunity to relax in the garden and make the most of their leisure opportunities. A requirement has been made in relation to this. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 19 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): 31,32,34,35,36 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Staff are adequately qualified as they now have access to NVQ assessors. The deputy is not receiving regular supervision so a consistent approach cannot be maintained. Service users are safeguarded by the home’s recruitment policy and procedures. EVIDENCE: The staff at Devon House had now started their NVQ level 2 and 3 and now have access to assessors. Staff were now receiving training in relation to mental health The certificates were not available at the home as they had been sent to head office. The manager has agreed to send copies of these on to the inspector. Staff were observed to have a clear understanding of their roles and responsibilities from the conversation the inspector had with them. Staff supervision records were inspected. The deputy manager is not regular supervision, which means that a professional, consistent cannot be maintained and it cannot be guaranteed that staff were adequate support and does not assist the development of service requirement has been made in relation to this. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 receiving approach receiving users. A Page 20 Staff records were inspected and found to contain all the necessary documentation e.g. criminal records bureau checks, staff references and the required staff identification records to ensure that adequate recruitment procedures were followed and that service users are being adequately protected from abuse. Staff meetings are taking place but not on a regular basis and not all staff meetings are recorded in the staff meeting folder. The manager explained that during the period that she had been off sick no replacement in terms of support for the acting deputy had been arranged and not all tasks were completed. All managers are in post and the manager informed me that staff meetings will take place on a regular basis to ensure that a consistent approach is maintained and staff have the opportunity to air their views. The staff rota was inspected at the time of the inspection and found to be in order with the allocated number of staff on duty in relation to service users. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 21 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): 37,39,41,42 Quality in this outcome area is poor. All appropriate health and safety measures need to be in place to ensure the safety and welfare of service users is maintained. There must be a registered manager working at the home to ensure a consistent approach is maintained to ensure the professional development of service users and staff. EVIDENCE: The current manager must apply to the Commission to become registered. This will provide a consistent professional management approach to support staff. This was a requirement made at the previous inspection, which has been restated at this inspection. The record of fire alarm tests, emergency lighting and fire drills were inspected and found to be in order. During a tour of the building the inspector noted that all fire doors were closed. All fire exits were clear and free from obstruction. The fire notices did not contain all the necessary information to indicate where service users need to meet in the Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 22 event of fire and what number is used to contact the fire service, which places them at increased risk in the event of a fire taking place. The fire door leading from the dining room to the lobby does not have an effective door closure and the door needs to be replaced to ensure that service users are adequately protected in the event of a fire taking place. A requirement has been made in relation to this. The company insurance was seen and found to be in order. The boiler and water test certificates were seen and various tasks were identified. The manager is in the process of consulting with the company in relation to the comments made and has agreed to inform the inspector of the outcome in writing. Environmental health had visited and documentation was found to be in order. The manager has ensured that the action required in the fire risk assessment has been completed. The London Fire and Emergency Planning Authority have been contacted and had visited the home. The manager now ensures that all key worker monthly recordings are kept up to date which ensures an adequate record of events is maintained. The manager and deputy manager are now trying to ensure that the contents of these meetings show a clear involvement of service users wishes and goals. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 23 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 X 3 X 2 2 X Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 24 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 YA6 Regulation 15 (1) (2) (c) Requirement The Registered Person must ensure that care plans contain the actions agreed at review meetings. The Registered Person needs to ensure that service user information is stored appropriately. The Registered Person must ensure that service users activity records are more accurately recorded to show the activities that service users undertake. The Registered Person must ensure that service users have access to a vehicle when they wish to attend planned trips out. The Registered Person must ensure that adequate procedures are in place in relation to the administration of medication and recording of medication. Timescale for action 01/07/06 2. YA10 17 20/07/06 3. YA41 17 20/06/06 4. YA11 16 (m) 01/10/06 5. YA20 13 (2) 01/06/06 6. YA24 16 (c) The Registered Person must 20/06/06 ensure the identified service user has his mattress replaced. The DS0000010655.V289873.R01.S.doc Version 5.1 Page 25 Devon House identified service user must have his wardrobe replaced or repaired. 7. YA24 23 (d) The Registered Person must ensure that the service users in rooms twenty-five and twentysix have their rooms decorated. 01/08/06 8. YA24 16 (2) (C) 9. YA24 23 (b) The Registered Person must 01/08/06 ensure that the identified service users in rooms six and twentyfive have their carpet replaced. The excessive items in room twenty-five must be removed. The Registered Person must 01/09/06 ensure that the kitchen doors are updated or repaired and the kitchen floor is sealed. The Registered Person must 01/07/06 ensure that the mixer valves are replaced to ensure consistent hot water to service users, which safeguards them from being scalded. The Registered Person must 20/06/06 ensure that the Deputy Manager receives regular supervision at least six times per year. The Registered Person must ensure that the fire notices contain all the required information. The fire door leading from the dining room must also be functioning effectively. The Registered Person must ensure that garden furniture is obtained. The Registered Person must ensure they apply to the Commission to become a Registered Manager. DS0000010655.V289873.R01.S.doc 10. YA42 13 (4) (a) 11 YA36 18 (2) 12 YA42 23 (4) (1) (3) 20/06/06 13 YA24 23 (g) 20/06/06 14 YA37 8 (2) 01/08/06 Devon House Version 5.1 Page 26 Requirement restated previous timescale not met. 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 YA14 Good Practice Recommendations The Registered Person should obtain activity materials that can be used within the home to enhance service users lives. Devon House DS0000010655.V289873.R01.S.doc Version 5.1 Page 27 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.V289873.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!