Inspection on 01/09/05 for Devon Lodge Retirement Home

This inspection was carried out on 1st September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Devon Lodge Retirement Home 05/04/07

Devon Lodge Retirement Home 02/02/06

Devon Lodge Retirement Home 01/12/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Devon Lodge Retirement Home Devon Lodge, 18 Theydon Avenue Woburn Sands, Milton Keynes Bucks MK17 8PL Lead Inspector Caroline Roberts Unannounced 1 September 2005 9:30am st 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 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 Older People. 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 Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Devon Lodge Retirement Home Address Devon Lodge, 18 Theydon Avenue, Woburn Sands, Milton Keynes, Bucks, MK17 8PL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01908 281470 0207 435 5168 Amberley Healthcare Ltd Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2004 Brief Description of the Service: Devon Lodge is situated in the centre of Woburn Sands, and ideally situated for access to the local amenities. Accommodation is over two floors, the first floor access via a shaft lift.The home has a lovely conservatory, which looks out, over the rear garden, which is very well maintained. The home has 20 single rooms and 3 doubles. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the un-announced inspection carried out at Devon Lodge on the 1st September 2005, between 12.45pm and 4.30pm. The lead inspector was Mrs Caroline Roberts. The inspection consisted of meeting with Residents and staff, viewing records and documents pertaining to the provision of care and the running of the home. The inspector toured the building, gaining permission from a number of residents to enter their bedrooms and viewing a further number from the doorway. The inspector met and discussed the inspection findings with the deputy manager, and manager before leaving. This inspection has resulted in tworequirements being served. The inspector found staff polite, helpful and welcoming, and would like to thank them for their co-operation and assistance throughout the course of the inspection. The inspector would especially like to thank the residents for their time and for allowing the inspectors into their home. What the service does well: The home has a good level of information on all of the areas required by the National Minimum Standards, which are generally maintained in good order. The home provides a clear and well-written description of its services, and promises to residents including residents own responsibilities which are clearly agreed on admission. All residents are admitted with a full assessment of their care needs. The food provided is good and the residents stated that they have choice offered and are happy with the food. All residents have an individual plan of care, which supports staff to implement appropriate care in a manner preferred by the service user. Personal care is implemented in a manner that ensures the privacy and dignity of residents is maintained. Staff have a clear understanding of individual residents needs, receiving additional training and support as needed to fulfil their roles. The Homes recruitment procedure ensures all necessary security checks are undertaken prior to employment. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 6 Visitors are welcomed at the home with no restrictions. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 Current and prospective residents have adequate information provided in the homes Statement of Purpose and Service User Guide, to enable informed choice about where they live. Written contracts are in place to ensure that residents have agreed the terms and conditions for living in the home. Though all residents at the home have needs assessments, these do not include Social and Leisure needs, which prevent the home from adequately meeting these needs. EVIDENCE: The homes statement of Purpose and Service User Guide were revised in June 2005, and clearly state the services and accommodation, which are to be provided. Detailed contracts are in place for each resident, which fully explain contractual terms and conditions, and copies are provided to privately funded residents, and to residents funded by the local authority. Specialist services and services which will incur additional costs are specified. Services include chiropody, dentistry, hairdressing and private shopping. Terms under which contracts will end are also described. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 9 Two residents assessments were examined and these showed good attention to health detail, but were absent in information regarding Social care needs and preferred leisure activities. The trainee manager had recently adapted the assessment form to ensure that health needs were being identified fully but has agreed to modify this form further to allow for social care needs. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 Assessed care plans were found to be up-to-date and were reflective of review, which enables staff to provide the required care. EVIDENCE: Residents care plans are based on needs assessments carried out by the home or by the referring agency. Plans regarding 4 residents reflected good detail regarding health, diet, and specific specialist needs and preferred daily routine. Discussions with the trainee manager about the need to expand on the social care and history were taken on board and will be monitored at the next inspection. Risk assessments are in place for all residents and are produced in a standard format showing the risk with a brief statement attached to each risk as to how it is to be managed. Evidence of a regular reviewing process was seen. Staff spoken with at the time of the inspection were knowledgeable of the individual needs of residents and the need for a holistic approach to care provision. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Not assessed during this inspection. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The complaints procedure is made available to residents and significant others, which ensures all relevant persons, are able to make formal complaints appropriately. EVIDENCE: The home has a complaints policy, which meets requirements, and which is understood by staff. The complaints policy is available for residents and relatives. The manager ensures that she meets with residents daily and meets with families when they visit the home. The home has received no complaints at the home or directly to the Commission in the past 12 months. The manager has an open door philosophy for residents, families and staff. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,26 Residents live in a safe well-maintained environment, which includes specialist equipment to maximise independence. The home is clean pleasant and hygienic throughout. EVIDENCE: The location of the home and its stated size and layout are well suited to the homes stated purpose and resident needs. It is a fairly modern, accessible home comprising of car parking facilities, large clean en-suite rooms with adapted bathrooms available. Residents have access to all communal areas and to their bedrooms at all times of the day and night. Grab-rails and a range of aids such as wheelchairs and walking frames are in use specific to assessed needs. The home has a well-maintained lift between floors. All rooms are fitted with a nurse call bell. The home has good facilities in place for cleaning, laundering and disposal of clinical waste. A full time maintenance man deals promptly with repairs. The home was very clean and free from any offensive odours. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Residents are supported by sufficient numbers of suitably trained and skilled staff ensuring the needs of residents are met at all times. The home has a full recruitment procedure in place, which is in line with Schedule 2 and Standard 29 of the National Minimum Standards. Residents are supported and protected by the homes recruitment practices. EVIDENCE: The home provides sufficient numbers of suitably trained and skilled staff to meet the needs of residents. The rotas were examined and this indicated that the home usually has four care staff on duty throughout the waking day and two during the night. The rota was well organised and easy to read. The home has a thorough recruitment procedure in place; ensuring necessary security checks are undertaken prior to employment at the home. The files of three recently appointed staff were viewed all contained a completed application form, 2 references, pova first check and CRB, well maintained interview notes were also on file. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The Health and Safety procedures and record keeping of the home ensures residents, staff and visitors to the home are protected as far as is reasonably practicable. EVIDENCE: The home has service agreements in place for: Boilers Lifts Hoists Electrical equipment Contractual arrangements are also in place for clinical waste. Fire safety records are well maintained. Moving and Handling update training is now required for some staff, the manager agreed to arrange this immediately, it was agreed that a requirement Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 16 would be served with a timescale for the training to be completed as 1.12.2005 First aid certificates also need renewing, requirement for completion 1.2.2005. The home still have a small number of radiators that need covering, the maintenance man is hand making all of the covers but it is anticipated that this will be completed by 1.11.2005, the manager is asked to confirm the completion of this task. Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 2 Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 18 no 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. 2. Standard 38 3 Regulation 13.5 14(1) Requirement Moving and Handling update training is required for staff. The manager must ensure that all residents needs assessments also include details of social interests and hobbies. Timescale for action 1.12.2005 1.12.2005 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 Good Practice Recommendations Devon Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 19 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park Smeaton Close, Aylesbury Buckinghamshire HP19 8JR 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 Lodge Retirement Home 20050109 Devon Lodge X00015 UI Stage 5 S36052 V247442 H53.doc Version 1.40 Page 20 - 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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