Inspection on 07/11/07 for Devon House

This inspection was carried out on 7th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 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 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 Key Unannounced Inspection 7th November 2007 10:00 Devon House DS0000010655.V354189.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.V354189.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.V354189.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 Since the previous inspection there have Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.craegmoor.co.uk Parkcare Homes Limited Vacant Care Home 14 Category(ies) of Dementia (1), Mental disorder, excluding registration, with number learning disability or dementia (14) of places Devon House DS0000010655.V354189.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. 21st May 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.V354189.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the inspection process. Compliance was checked against key standards. The inspection took approximately 8 hours. The manager and deputy manager assisted both myself and another person who is referred to as an expert by experience who joined the inspection at approximately 11: 00am. We undertook a tour of the building, interviewed people who live in the home. We observed the interaction between people living and working in the home. Further information was obtained by an inspection of the documentation kept in the home including care plans and health and safety documentation. I would like to thank all of those present for their openness and participation. What the service does well: What has improved since the last inspection? The homes statement of purpose has been updated to ensure that accurate information is recorded and made available to people living in the home. Effective monitoring and recording is now in place in relation to people smoking in their bedrooms which poses a health and safety risk with regard to a fire taking place within the home. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 6 Service user meetings are now taking place, which provides people with the opportunity to express their views, which empowers them. Key worker meetings are now taking place as agreed in peoples individual care plans, which makes people living in the home feel valued. People are being supported to maintain contact with their relatives, which benefit their emotional wellbeing. People have keys to their rooms which some of them use which assists to ensure that their privacy is respected. A number of environmental improvements have taken place, which include one person being provided with an easy chair for their bedroom. One person’s bedroom has been redecorated and their carpet has been replaced. The water leak has been investigated in the down stairs bathroom and the pipes have been boxed in. The hall carpet has been cleaned. These improvements all contribute to making the home a more pleasant place to live. The manager has been appointed and made an application for registration. The deputy manager has also been appointed along with the life skills coach, which assists to improve the quality of care provided in the home. What they could do better: The care plans need to be fully complete and detailed to ensure that people’s needs are met and the person centred planning needs to be fully implemented. The deputy manager has made a start at ensuring that all of the individual people’s risk assessments are updated to ensure that all risks to their health and safety are minimised. Not all risk assessments are complete and up to date. The activity programme needs to be expanded to include more leisure and education opportunities, which will enrich people’s lives. The efforts to engage people in an activity that has been recorded as declined or refused must be noted on the activity records to ensure that effective recording is maintained. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 7 People must attend all of their health care appointments to ensure that their individual health care needs are met. The complaints policy must be given to all of the people living in the home to ensure they have a clear understanding of the process. Some additional improvements in relation to the home need to be undertaken particularly in relation to the ventilation and adequate functioning of the shower in the shower room. One person’s bedroom needs to be decorated. A new loft hatch has to be placed on the entry to the loft to further improve the home environment. The two individual people whose televisions were not working need to be working correctly as a matter of urgency. Staff supervision must be undertaken for all staff including the deputy manager to ensure that the effective running of the home is maintained. All records must be properly organised and complete to enable ease of access to information as required. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Devon House DS0000010655.V354189.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.V354189.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 the service receive a Good outcome. This judgement has been made using available evidence including a visit to this service. People do have the information they need to make an informed choice about were they want to live as a service user guide is available. No new assessments have been undertaken since the previous inspection due to no new people moving into the home. EVIDENCE: At the time of the previous inspection one person who had been newly referred to the home did not have adequate documentation available in relation to the admission and assessment process. This meant that the staff at Devon House could not ensure that this person’s individual needs could be met. Due to the individual persons high level of increasing health care needs they were admitted to hospital and did not return to the home. A more suitable placement needed to be identified to ensure that the person’s needs were fully met. The area manager has discussed this area of concern at a meeting held at the CSCI area office. The area manager has confirmed that no new people will not be admitted in future to the home without a full assessment of their individual needs taking place. The statement of purpose has been updated which ensures that accurate information is available in relation to the service. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 10 The service user guide was seen and it ensures that people who may wish to move into the home have the information they need to enable them to make a choice about were they want to live. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, People who use the service receive an adequate outcome. This judgement has been made using available evidence including a visit to this service. Not all of the people’s care plans are being kept up-to-date. They need to contain more detailed information to be fully effective. People do make decisions about their lives, which ensures their wishes are respected. The service must further improve with regard to supporting people to take risks to develop an independent lifestyle. EVIDENCE: A new manager and deputy manager are now in post. They informed us that they are in the process of updating the care plans. The manager, deputy manager and team members are just beginning to introduce person centred planning. This will ensure that people’s care plans are more specific in relation to their individual needs. A number of care plans were inspected and they need to be more detailed and fully completed. However they are being evaluated monthly and the information contained within them is being read to see which information is still accurate and valid. This should improve the quality of care people receive in the home. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 12 The risk assessments are in the process of being reviewed and updated. The risk assessments cover areas including depression, smoking in the bedroom, physical and verbal outbursts and self-neglect. A number of the documents have been updated having been reviewed. However there are a number of risk assessments that still need to be updated. I was of the opinion that the importance of this task to ensure that the risks identified in relation to people’s individual needs and the need to minimise these risks to safeguard people’s health and wellbeing was being taken seriously by the management team. On the day of the inspection the recorded room checks that are carried out by staff to remind people that they must not smoke in their rooms had been completed which ensures that effective safety checks are taking place, which promotes people’s health and safety. Service user meetings are now taking place. People were asked if they are happy and did they feel valued in the home. When one person was asked about this she said,” I feel safe and secure in the home”. People had discussed the menu for the Halloween party a buffet had been discussed as well as individual meals. The activities were discussed and the fact a new pool table is needed which has been ordered. This ensures that people living in the home have the opportunity to express their views. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17, People who use the service receive an adequate outcome. 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 but this needs to be expanded further to enrich people’s lives. 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 recognised which makes them feel valued. People are offered a healthy diet, which promotes their good health. EVIDENCE: At Devon House the previous life skills coach had left and a new person has been appointed. There was some initial confusion when I and the expert by experience asked to see the activity records. The manager who it was observed was attentive. However he did provide the wrong records to us. The records, which were insufficient in terms of the recording procedures. The deputy manager then joined us as she was due to work the afternoon shift. The deputy manager then showed us the correct activity records and the expert by experience and I both felt that progress we made was made a lot Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 14 easier. The life skills coach and staff team need to develop further the activity programme and expand the activities that are being undertaken. The programme needs to include the opportunity to undertake leisure and educational opportunities. This will increase people’s opportunity of social interaction and personal development, which will increase people’s selfesteem. As the expert by experience reported the people seemed “happy and relaxed but some people appeared a bit bored”. One-person activity records indicated that the only activity they had participated in was to read the papers and spend time in his room. The deputy manager explained that it is difficult to involve particular people in activities. I noted that the activity records indicate that certain people are believed to be confused and decline the opportunity to participate in activities. However the efforts undertaken to engage people in activities must be recorded. The deputy manager explained how she had tried to organise a holiday but this opportunity had been declined by the people living in the home. There were clear examples of some activities that were being undertaken for example, one person spoken to attends the community centre and takes part in art, craft, yoga and is also involved in the church. This person is very active within the local community. One person also went to a star wars convention and stayed overnight in a hotel, which acknowledge his particular interests and values his personal wishes. “We spoke with this person and he said, “I enjoyed the star wars outing very much and would like to go again.” Other people had been offered the opportunity to assist with the Halloween party. They also attend a party that was taking place in another of the organisations homes. I was pleased to see that activities and people’s wishes in relation to these are discussed in the individual key worker meetings. To ensure that these meetings are meaningful it is important that people’s wishes such as going to a restaurant, colouring or shopping for new clothes are acted upon. The manager and deputy manager were asked if a vehicle was available for the people living in the home to use for day trips and outings and could be used to encourage people to take part in activities .The managers said that they do not have a vehicle available to them. I believe that the possibility of obtaining a means of transport should be considered by the organisation. Two of the people living in the home receive regular visits from their relatives, which benefit their emotional wellbeing. However these must be more effectively recorded to ensure that an up-dated record of visits is maintained. People have keys to their bedroom which some of the people living in the home use, which assists to ensure their privacy is respected. There is also acknowledgement of the restriction of people’s liberty and this is in relation to room checks taking place in relation to people smoking in their bedrooms. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 15 On the day of the inspection the kitchen was clean and tidy. The fridge and fridge freezer was inspected and food stored in the fridge was labelled appropriately. 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 which ensures that people’s dietary needs are being met. The food is ordered on the Internet and delivered to the home. One person spoken said “ the food is lovely and I help cook the roast on a Sunday.” Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. People do not have access to all the necessary health care appointments which means their individual health care needs are not being fully monitored. People living in the home are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: People have access to primary and specialist healthcare appointments. However two people needed an appointment to see the dentist to ensure that their individual health care needs are met. The manager informed us that the General practioner was contacted in relation to one person who it was felt may have the flu and was declining to take his medication. The general practioner had not phoned the home back in relation to this matter. I asked the manager to contact the general practioner again to ascertain the reason for this and discuss the necessary action that needs to take place to ensure this person’s health care needs are met. The manager has also confirmed that he is going to discuss this person’s needs with their CPN. The medication and administration records were inspected and they were found to be in order, which ensures that effective recording is taking place. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 17 This safeguards the wellbeing of people living in the home. The home also has available the sample signatures of staff who are able to administer medication. This list is kept in the medication cupboard and the management team have agreed to place a copy of this document in the medication folder, which, helps ensure that good practice is followed. This will prevent errors in relation to the administration of medication taking place. People were appropriately dressed at the time of the inspection. I saw a clear improvement in the people’s appearance. I also saw evidence of people’s specific hygiene needs being discussed with them in their key worker meetings. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. Not all People felt their views were listened to and acted upon which does not make them feel valued. People are protected from abuse neglect and self-harm. EVIDENCE: At the time of the unannounced inspection. The person who accompanied me on the inspection who is referred to as an expert by experience asked to look at the complaints book. I was informed that the last complaints made were logged in august 2007 and were completed in the same persons handwriting. I was also informed that the complaints procedure was available in the hall of the home and consisted of one piece of paper pinned to an over crowded notice board. No other information in relation to how to complain was identified. There was also no evidence of advocacy contacts. The homes manager has agreed to ensure that the complaints policy is given to all of the people living in the home and obtain a copy of their signature to confirm this has taken place. This will also be included in their individual files. The policy on whistle blowing was seen and found to be in order. During the inspection the complaints process was discussed with the people living in the home to ensure that they knew how to make a complaint and allow them to express any concerns they had. One person said that his television had been broken for several months and no action had been taken in relation to this. Another person expressed concern in relation to their television not working. This issue was raised with the management team. (Further referred to in the section headed environment.) Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 19 The homes policy on adult protection procedures could not be located on the day of the inspection. The placing authorities adult protection procedures also could not be located. These documents have now been located and were sent to me prior to the report being completed with a letter from the manager confirming that they were in the office of the home and available to staff. This ensures that the staff have the necessary information available to them to protect people living in the home from potential abuse. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 20 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. This judgement has been made using available evidence including a visit to this service. People in the home have benefited from recent improvements in their home environment. Although there are still environmental issues that need addressing to ensure they live in a homely environment. EVIDENCE: Devon House is located in a residential area near to local shops and public transport. We completed a tour of Devon House and a person who currently lives there showed us around the home at our request. We inspected people’s bedrooms having sought their permission. The person who was sitting on a garden chair in his bedroom now has a new easy chair to ensure he is comfortable and can relax when sitting in his bedroom. Room six has now been redecorated and the carpet has been replaced with laminate flooring, which ensures that the person has a pleasant bedroom to relax in. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 21 The hall carpet has now been cleaned which ensures that the levels of hygiene are maintained and benefits the health and wellbeing of those people living and working in the home. The person in room twenty-five has removed the excessive amount of items that were stored and posed a potential fire risk. This ensures that the new management team is taking health and safety seriously and further protects people living in the home. Both the ex by ex and I were told by this person “I am very happy with my bedroom and I will not let my stuff build up again.” The ground floor bathroom has now been investigated in relation to the water leak. The water pipes that were exposed have been boxed in but still need to be painted, which will ensure the home is well maintained. The shower on the first floor had the fixtures and fittings in relation to the shower in pieces on the floor. This shower has frequently been affected by the build up of mould due to poor ventilation. The previous manager informed me at the last two inspections that she has identified an extractor to be fitted in the shower room. The new manager was of the impression that this was the new ventilation system. I have clarified that this is the old ventilation system, which was seen at the last inspection, and it still needs to be replaced and the work needs to commence as a matter of urgency. The management team have ordered new tables, chairs and curtains for the lounge. The lounge is also going to be redecorated when this is completed it will ensure that people living in the home are provided with a more appropriate environment in which to eat their meal and socialise. The toilet in room six, which appears to be showing the initial signs of damp must be investigated and the appropriate action needs to be taken to ensure the person’s health and safety is safeguarded. The toilet then needs to be redecorated once the work has been completed. One identified persons bedroom (room 7) needs to be redecorated as the paintwork is dirty and does not promote a homely environment. The loft hatch, which is missing and would allow unhindered access of those living in the home into the loft, must be replaced to protect people from harm. Two people living in the home one in room twenty- four and six both expressed the fact that their televisions were not working effectively. This was discussed with the management team on the day of the inspection. The manager did take immediate action to remove the small television from the staff room and provide it to one of the people whose television was not working. It was agreed that the televisions would be repaired or replaced due to the impact this currently has on the quality of life that is being experienced by people living in the home. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 22 The expert by experience took the opportunity to speak with a number of people living in the home and he felt that the environmental improvements had “created an air of optimism and he found it a pleasure speaking with people living in the home”. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 23 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. This judgement has been made using available evidence including a visit to the service. The staff team are now working more effectively as staff vacancies have been advertised. People are safeguarded by the homes recruitment policies and procedures. Staff are supported by appropriately qualified staff. 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 made an application for registration. However the documentation was sent to the appropriate team quite late. The new manager is being supported by deputy manager in relation to his role of ensuring the home is run 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 who had left their post just after the last inspection has had their post advertised and a new member of staff has been appointed which should improve the consistency of care provided to people living in the home. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 24 Staff are now undertaking their NVQ level 2 which ensures they are better trained to meet the individual needs of people living in the home. The staff recruitment policies and all relevant documentation was inspected. One persons CRB or Protection of vulnerable adults check was not available at the home but had been sent to the organisations head office. At my request the document was provided to me and found to be in order. The fact that it is essential that such documents are available at the time of the inspection and kept securely at the home was stressed to the management team. The consequences of failing to do this were also explained. Staff supervision is not taking place for all staff as the deputy manager’s supervision had not been completed which means that staff are not being supported to work with people living in the home in a consistent way. The deputy manager has informed me since the inspection took place that her supervision has been completed. The manager did explain that in the future the responsibility of the staff supervision will be shared between the manager and deputy to ensure there is a workload balance, which will make this area of the work easier to manage. The manager must ensure that all records in the home are properly organised and completed to enable ease of access to information as required. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The newly appointed management team are currently beginning to send out quality assurance information. Until this task is completed and the information received is compiled into a report and acted upon I cannot confirm that people’s views underpin all self- monitoring review and development in the home. We inspected a range of health and safety documentation. A fire Drill had taken place on the 20/09/07. The fire alarm had been inspected and the fire risk assessment was seen and was dated 17/7/07.The weekly bell test were not being undertaken on a regular bases. The deputy manager has informed me that they are now taking place and being recorded effectively. The electric Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 26 and gas certificate have been seen and were found to be in order. The liability insurance certificate was seen and found to be in order. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 27 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 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 3 STAFFING Standard No Score 31 X 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 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X X X 3 X X 2 X Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 28 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) Timescale for action The Registered Person must 12/02/08 ensure that care plans are detailed and kept up to date so that people’s individual needs are fully met. The Registered Person must ensure that all risk assessments are detailed and kept up- to date so that all risks to people living in the home are minimised, which will assist to safeguard them. The Registered Person must ensure that service users activity records are more accurately recorded to show how staff have attempted to engage people in an activity when it is refused. The Registered Person must ensure there is a clear record of relative’s visits so that it is evident how staff are supporting people to ensure their emotional needs are being met. The Registered Person must ensure that people are supported to access more structured activities including educational opportunities so that people’s DS0000010655.V354189.R01.S.doc Requirement 2. YA9 15 (2) 25/01/08 3. YA41 16 15/01/08 4. YA41 15 20/01/08 5. YA12 16 (2) (n) 20/02/08 Devon House Version 5.2 Page 29 lives are enriched. 6. YA19 12 The Registered Person must 12/01/08 ensure that all health care appointments are undertaken. This must include dental appointments so that people’s health care needs are fully met. The Registered Person must 24/12/07 ensure that all of the people living in the home are provided with a copy of the organisations complaints procedure. An up-to date copy must be available on the homes notice board so that people are fully informed regarding the complaints process. The Registered Person must 01/01/08 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 effectively. This requirement has been restated. The previous timescales of the 24/11/06, 21/05/07 were not met. The Registered Person must 20/12/07 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. The registered Person must 10/12/07 ensure that the loft hatch is replaced so that people will be living in a safe environment. The Registered Person must 20/01/08 ensure that the identified person in room seven has their room DS0000010655.V354189.R01.S.doc Version 5.2 Page 30 7. YA22 22 8. YA27 23 (b) 9. YA42 23 10. YA24 23 2 (b) 11. YA24 23 2 (d) Devon House 12. YA24 23 b (b) 13. YA36 18 (2) 14. YA41 17 ( 3) decorated so they are provided with a pleasant place to live. The Registered Person must 10/12/07 ensure that the two people who have expressed concern that their televisions are not working are repaired or replaced to ensure they are working effectively so that this does not impact on their social activities. The Registered Person must 10/01/08 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 has not been met. The Registered Person must 10/01/08 ensure that all the records in the home are properly organised and completed to enable ease of access to information as required. This will ensure effective recoding systems are maintained. This requirement has been restated. The previous timescale of the 21/05/07 was not met. The Registered Person must 04/12/07 ensure that weekly bell tests are completed with no gaps in the recording so that the health and safety of the people living in the home is promoted. 15. YA42 15 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 31 1. YA11 The Registered Person should ensure that people have access to a vehicle when they wish to attend planned trips. Devon House DS0000010655.V354189.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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.V354189.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. 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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