Inspection on 02/02/06 for Devon Lodge Retirement Home

This inspection was carried out on 2nd February 2006.

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

The inspector 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 01/09/05

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 Mrs Caroline Roberts Unannounced Inspection 2nd February 2006 2pm X10015.doc Version 1.40 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 Lodge Retirement Home DS0000036052.V282081.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 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 DS0000036052.V282081.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Devon Lodge Retirement Home Address Devon Lodge 18 Theydon Avenue Woburn Sands Milton Keynes Bucks MK17 8PL 01908 281470 0207 435 5168 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) Amberley Healthcare Ltd Elizabeth Helen Fellows Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 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 DS0000036052.V282081.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Each care home that is registered with the Commission for Social Care Inspection, receives one announced and one unannounced inspection each year and further additional visits as necessary. All inspections, both announced and unannounced are followed by a written report, which eventually become public documents. It is a requirement that inspection reports are made available within the home. This inspection was unannounced and took place on the 2nd February 2006. The inspectors present were Mrs Caroline Roberts (Lead Inspector) and Mr Guy Horwood (Inspector) This 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 Inspectors 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 inspectors met and discussed the inspection findings with the manager before leaving. This report has resulted in no requirements being served; the manager and staff team are to be congratulated for their continued hard work. What the service does well: What has improved since the last inspection? Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 Page 6 The manager has settled into her role very well. NVQ training continues. 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 DS0000036052.V282081.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 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 the following standard(s): 6 Standards not assesses during this inspection. EVIDENCE: Intermediate care is not provided in this home. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 8,9,10. There are robust medication procedures in place to ensure that resident’s medications are appropriately administered and securely stored. All the staff understand the issues around privacy and dignity, and the residents are treated with respect. EVIDENCE: Dentist, chiropody, and opticians are all readily accessible to the residents. Any visit by a healthcare professional is documented within the health intervention section of the care plan. Daily reports were found to be well completed. Medications are received into the home and noted on the medication administration record (MAR) sheets provided by the pharmacy. Medications to be returned to the pharmacy are fully documented with records maintained. Medication is stored securely and as per pharmacy instruction. The home only holds a minimal stock of medications. The home have a controlled drug register for any controlled drugs staff countersign for any controlled drugs administered. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 Page 10 Policies and procedures give clear instruction with regards to handling, storage and administration. Staff were observed knocking on doors before entering rooms. Residents were assisted with their meals sensitively and conversation between residents and staff was relevant and caring. Staff responded to any request for help promptly and willingly. Residents and a relative stated that care staff treat residents with respect, and are careful to retain their dignity. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14,15. The daily life and social activities provided match the resident’s preferences and interests. Residents receive a wholesome nutritious diet, and every effort is made to ensure that meal times are a pleasurable experience. EVIDENCE: Residents spoken with said that they were able to choose how they wished to spend their day and were not made to feel uncomfortable if they chose to stay in their own room, and not join in the activities provided. Others were pleased to have a varied programme of activities to enable them to lead a full and active life. The staff make every effort to find out what the individual resident’s life style, and preferences are and these are documented in the care plans. Residents spoken with described how they enjoyed the food. The cook described how efforts are made to incorporate resident’s favourite dishes into the menu. Residents are offered three meals a day with homemade cakes and other snacks available in between times. Mealtimes are unhurried. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 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 the following standard(s): 18 Residents are protected from abuse through the homes policies and staff training. EVIDENCE: The training records of the staff seen contained evidence that Protection of Vulnerable Adults (POVA) training had been done and more projected dates were available to ensure all staff undertake this training. Ancillary staff are invited to any training-taking place at the home. Copies of the Milton Keynes Adult Protection Policies are available in the home. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: Standards not assessed during this inspection. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Staff are well trained and competent to undertake their duties fully. EVIDENCE: The manager is in the process of updating further the training and development records and creating a spreadsheet. Current records seen evidences that all mandatory training is up to date with update training planned as needed. Individual certificates are held within the staff personal records. All staff receive 3 days per year paid training. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35. Residents live in a home, which is run and managed by a person who is experienced and able to discharge her responsibilities fully. Effective quality monitoring ensures that this home is run in the best interests of residents. EVIDENCE: Mrs Fellows has recently become the registered manager, she has many years experience of working with older people, in various senior positions. During the inspection residents spoken with said they felt able to approach the manager if there were any issues they wished to raise. These comments were made without hesitation. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 Page 16 The manager has not yet sent out any quality assurance questionnaires since commencing her post as registered manager, this is a task she is hoping to commence within the next month. Monthly audits are undertaken on the care planning system with records maintained. A medication audit is undertaken twice yearly again the manager maintains records. Environmental audits are undertaken monthly with the help of the maintenance person. The manager has agreed to devise an action plan from all this information gathered, and give feedback to residents and relatives. Progress with this piece of work will be monitored at the next inspection. The home does not handle any resident’s finances. Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A X X x Devon Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 Lodge Retirement Home DS0000036052.V282081.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury 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 DS0000036052.V282081.R01.S.doc Version 5.1 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. 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!