Inspection on 05/04/07 for Devon Lodge Retirement Home

This inspection was carried out on 5th April 2007.

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 02/02/06

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 Joan Browne Unannounced Inspection 4th & 5th April 2007 11:30 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.V331003.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 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.V331003.R01.S.doc Version 5.2 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 zoe.hutchins@tesco.net 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.V331003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: Devon Lodge is a care home providing personal care for twenty-six older people. Amberley Health Care Ltd owns the home, which is a private limited company. The home is situated in the centre of Woburn Sands, close to local amenities. The home was originally registered in 1990 and consists of a two-storey building with a conservatory. The home has twenty single bedrooms and three double bedrooms. All rooms have en suite facilities. There is a communal sitting room, a dining room and a quiet lounge with a library. The home has three assisted bathrooms with toilet facilities and two shower facilities. There are two passenger lifts and a garden at the rear, which is well maintained. The current weekly fees range from £530.00- £750.00. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced ‘Key Inspection of the service, which took place on 4 & 5 April 2007. Prior to the fieldwork visit previous information about the home was reviewed and the outcome of previous inspections noted. The inspection consisted of the case tracking of four service users from their original contact with the home to the care that that they are now receiving. Discussions took place with other service users, staff members, the manager and five relatives who were visiting the home at the time of the inspection. Staff’s practice was observed, care documentation and records were examined and a tour of the building was conducted. The Commission received feedback from eighteen service users. Comments made were very positive. Service users were happy with the care provision and were complimentary about the manager and the staff team. Relatives spoken to during the inspection were equally happy with the care provision. From evidence seen and comments received, it is considered that this service meets service users’ cultural, religious and diverse needs. The inspection process highlights the home to be one, which is very well run with high standards of care. The inspector would like to thank the manager, service users and staff for their hospitality and time during the inspection. What the service does well: No service user moves into the home without having her/his needs assessed and are assured that the home can meet their needs. Service users’ care plans are reflective of their care needs thus ensuring that all identified needs were being met. Service users are treated with dignity and their right to privacy is upheld. The home has an activity programme in place to ensure that service users’ social and recreational interests are catered for. Visitors are able to visit at any time thus ensuring that service users are supported to maintain contact with their families and friends. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 6 Service users receive a varied and appealing diet and are supported in their choice of meals in accordance with their assessed needs. Service users and their relatives have confidence in the home’s complaints procedure thus ensuring that their concerns will be listened to and acted upon. Service users are protected from abuse by the home’s policies and procedures, which include training for staff. The home is well maintained thus ensuring that service users live in a comfortable and safe environment. The needs of service users are met by a suitably trained and skilled staff team with sufficient numbers of staff employed to meet service users’ assessed needs. The home has an effective recruitment procedure, to ensure that staff employed are appropriately vetted to care for service users. The home has health and safety systems in place to ensure that service users health and safety are protected and promoted. What has improved since the last inspection? What they could do better: The home should ensure that a recent photograph is held on each service user file for clear identification. The home should review how it stores medication to ensure that medication prescribed for external use such as lotions and creams are not stored on the same shelf with oral medication. In the interest of safety the home should ensure that a second person check and witness the recording of Temazepam medication in the controlled drug register when it is delivered by the pharmacy. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 7 The home should review its current system in place when amending individuals’ Warfarin dosage to ensure that verbal request of change is followed up by written confirmation. The home should ensure that handwritten medication administration record sheets should be witnessed by a second staff member whenever possible. Recent photographs of staff members should be kept on file to confirm proof of identity. 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 Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 8 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.V331003.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home ensures that prospective service users care needs are assessed before moving into the home to ensure that needs identified would be fully met. The home does not offer intermediate care and therefore standard 6 is not applicable. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 10 EVIDENCE: Four service users care was tracked. Case tracking confirmed that the home has an assessment tool in place and service users needs were assessed prior to being admitted to the home. The manager explained that prospective service users are visited in their own home, hospital or invited to the home to undertake an assessment of their care needs. Two visitors spoken to during the inspection confirmed that staff had undertaken a comprehensive needs assessment on their relative before admission. They felt that the assessment was carried out with skill and sensitivity and staff had spend time getting to know their relative and were able to answer questions. Information seen relating to contracts, fees and terms and conditions of occupancy was clear. Service users are offered a months trial period. Staff spoken to were able to describe the admission and assessment process and were confident that new service users are made to feel welcome. The four assessment documentation examined contained detailed information outlining how individuals’ social, emotional and personal care needs would be met. For those service users who are funded by a placing authority the manager said that the home would obtain a copy of the care management assessment summary and care plan to ensure that the home would be able to meet all identified needs. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that systems are in place to ensure that service users health care needs are appropriately met. However, some improvement is needed in the safe handling and recording of medication to enhance the delivery of service further. EVIDENCE: Four care plans were examined. Case tracking confirmed that plans contained detailed and clear actions allowing staff to care appropriately for individuals. There was also a comprehensive moving and handling risk assessment in care plans seen. Files failed to contain a recent photograph of service users. A recommendation is being made in this report for photographs to be held on service users files for clear identification. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 12 The home has a system in place to ensure that care plans are reviewed and updated monthly and service users’ weights are monitored and recorded. Through case tracking service users confirmed that they were receiving the care and support as reflected in their care plans. The plans seen were signed by service users or their representatives to confirm their involvement in the care planning process. Relatives spoken to during the inspection said that they were kept informed of any changes to the care plan. The daily report writing reflected how individuals personal, social and psychological needs were being met. The home ensures that service users are registered with a general practitioner who reviews their medical and health care needs at regular intervals. They also have access to other health care provision such as dental, optical and chiropody treatment. Staff work closely with other health care professionals such as the district nurse, physiotherapist and continence adviser to ensure that service users have the necessary aids and equipment to enhance the quality of their life and to maximise independence. The manager confirmed that the home has a medication policy for the safe handling, recording, and administration of medicines. The home will support those service users who are able to take responsibility for their own medication within a risk management framework. On the day of the inspection there were no service users who were self-medicating. The home uses a (MDS) monitored dose system. An appropriate lockable storage trolley was in place to accommodate the MDS containers. There was evidence that an audit trail of all medication entering and leaving home was in place. It was noted in the stock medication storage cupboard that creams, lotions, liquids and tablets were stored together. In the interest of safety it is recommended that medication prescribed for external use such as creams and lotions should not be stored on the same shelf with tablets. The medication administration record (MAR) sheets were examined and no gaps were found. The home was ensuring that Temazepam medication, which is a sedative, was treated as a controlled medication. The controlled drug register was checked and the stock balance corresponded with the register. It was noted that two staff members sign the controlled register when it is administered. However, this was not the case when it is received from the pharmacist and recorded in the controlled register. As a good practice and in the interest of safety it is recommended that two staff members should sign for the receipt of Temazepam medication or any controlled medication. It was noted that two service users were on Warfarin medication (which is a medication given for thinning the blood). It is also a prescription only medication. The administration dosage of the medication can be reduced or Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 13 increased depending on blood tests that are carried out monthly. It is recommended in the interest of safety that the current system in place when amending individuals dosage should be reviewed to ensure that verbal requests of change is followed up by written confirmation. It is also recommended that the home should seek the advice of a pharmacist with regard to potentially adverse reactions between food and warfarin and that such advice is incorporated into the service user’s care plan. It is further recommended as a good practice and in the interest of safety that handwritten entries on MAR sheets should be witnessed by a second staff member whenever possible. Service users confirmed that staff ensure that their privacy and dignity are upheld when providing personal care. Staff were observed interacting sensitively with service users and knocking on their bedroom doors and waiting for a reply before entering. The manager said that she often observes staffs practice and their attitude and approach to service users privacy and dignity. Feedback from service users on how staff promote their privacy and dignity when assisting with personal care was positive. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a wide range of activities within the home for service users to participate in. Mealtimes are enjoyable and a social occasion for all service users served in pleasing surroundings. EVIDENCE: The home has an activity organiser who is responsible for facilitating meaningful activities in the home and the wider community. The weeks daily activity was displayed in the home for service users and their relatives to be aware of the planned activities taking place. Regular trips to the local garden centres are arranged. Boat trips on the Bedford River are also arranged during the summer months. Entertainers visit the home regularly to perform and outings to the theatre take place. The manager said that a yearly summer barbecue is held for service users, relatives and staff. Those service users who wish to practice their religion are supported to do so and church services take place regularly in the home. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 15 It was noted that some service users with assistance from the activity organiser had made Easter cards for relatives and friends. They had also designed special Easter menus for the Easter lunch that was taking place on Easter Monday. Service users who responded to the Commissions comment card said that activities were always or usually organised. Those spoken to during case tracking confirmed that their views are sought and they are consulted when planning activities. They are able to choose what they wish to do. Some choose not to participate in activities and their wishes are respected. The home does not have restrictions on visiting. Relatives and friends are able to visit anytime within reason and staff support service users to keep in contact with family and friends. Relatives spoken to during the inspection confirmed that they are made to feel welcome by the staff team and are always offered refreshments. They are also able to participate in a meal if they wish to. One service user commented the following: the staff always offer my son and daughter-in-law tea and biscuits when they visit. Service users are helped by staff to exercise choice and control over their lives by empowering them to maintain their independence and to be responsible for their own finances. They are made aware that they are entitled to bring personal possessions with them, which is agreed prior to admission. They are also made aware of their rights to read their care records if they wish to. The cooks employed in the home are qualified and experienced in cooking for older people and are aware of their dietary needs, likes and dislikes. Lunch was observed which consisted of roast pork, roast potatoes, stuffing, carrots and cabbage. There was a choice of coconut sponge with custard or melon for dessert. The dining room was warm and welcoming. Tables were covered with tablecloths with matching serviettes. There were sufficient cutlery and condiments available. Fruit juices and water were readily available. Lunch was a relaxed and social occasion and was tasty. Service users who completed comment cards said that meals at the home were always enjoyable. The following additional comments were noted: Lovely food well presented all homemade and delicious always have a nice variety. Staff were observed assisting those service users who needed assistance in a sensitive and discrete manner. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users and their relatives were confident with the home’s complaints procedure and as a result feel safe and listened to . All staff undertake regular updated training in safeguarding of vulnerable adults, which ensure that the homes procedure is understood and consistently applied. EVIDENCE: Information on the pre-inspection questionnaire indicated that the home had not received any complaints about the service. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. An incident was reported under Regulation 37 relating to a staff issue. This was discussed with the home manager during the inspection who confirmed that there was a satisfactory outcome to the investigation. The homes complaints procedure was available to all service users, which was included in the service users guide. All service users spoken to during the inspection said that they knew who to speak to if they had a concern. They felt that the manager and staff were approachable. They stated that they were extremely satisfied with the service provision and felt very safe and well supported. The inspector was shown thank you notes from relatives of service Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 17 users who are now deceased expressing their gratitude for the high standard of care that was provided. The Commission has not received any information concerning any suspicion or evidence of abuse or neglect made to the service since the last inspection. Staff spoken to had a good understanding of the safe guarding and protecting the rights of service users. Information submitted on the pre-inspection questionnaire indicated that staff training in safeguarding of vulnerable adults was up to date. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides service users with a safe and well maintained environment to meet their diverse needs. EVIDENCE: The home is suitable for its purpose it is safe and well maintained with a real family atmosphere. Bedrooms and communal areas viewed were clean, tidy and well presented with no odours. Service users and visitors spoken to were complimentary of the high standard of cleanliness in the home. There is a call system in bedrooms and communal areas to alert staff in the case of an emergency or when required. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 19 The manager said that there was a programme of routine maintenance and renewal of the fabric and decoration of the premises in place. She also confirmed that any requirements of the local fire service and environmental health department visits are immediately acted upon. The home employs a maintenance person who ensures that the grounds are kept tidy, safe, attractive and accessible to service users. Service users are encouraged to bring small items of furniture, family pictures and memorabilia, which were evident in their bedrooms. Sufficient bathrooms, toilets and shower facilities were available with grab rails, and specialist equipment to maximise service users independence. The laundry room was clean and tidy and is fitted with the appropriate washing machine with the specified programming ability to meet disinfection standards. The walls and floor were impermeable. Hand washing facilities were prominently sited. Clinical and general waste is properly managed and stored. The home has an infection control policy, which staff adhere to. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff who are approriately trained and recruited to meet their diverse needs and to proctect them from any potential risk of harm. EVIDENCE: The staffing numbers on the day of the inspection were sufficient to meet the needs of the service users. There were four carers covering the morning shift, two domestics, the maintenance person and the cook. The manager was supernumerary to the rota. Service users and relatives spoken to during the inspection said that the home was always well staffed. Feedback in service users surveys indicated this information as well. Information submitted in the pre-inspection questionnaire indicated that thirteen of the sixteen care staff had achieved the national vocational qualification (NVQ) at level 2. A further two staff members will be commencing NVQ at level 3 and 4. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 21 The home operates a good recruitment procedure to ensure that staff are satisfactorily recruited to protect service users. Five staff members files were examined and they contained all the information and documents specified in Regulation 19 and Schedule 2 apart from recent photographs of individuals to confirm proof of identity. A recommendation is made to ensure that recent photographs of staff members are kept on file to confirm proof of identity. It was noted that staff were not issued with copies of the general social care council (GCCC) code of conduct guidelines. To enhance staffs knowledge and skills it is recommended that all staff be issued with a copy of the GSCC code of conduct guidelines. All new staff undergo induction training and are expected to shadow an experienced staff member until feeling confident. The manager confirmed that in addition to the homes induction training all new staff undertake on track training which covers first aid, manual handling, and food handling and hygiene with the local college. Information submitted in the pre-inspection questionnaire indicated that core training for all staff was up to date. The manager said that staff show a healthy interest in all aspects of training. They are provided with training on dementia, infection control, safeguarding vulnerable adults, health and safety, fire awareness and other specialist training that is targeted and focussed on improving outcomes for service users. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has audit systems in place to ensure that the home is run in the best interests of service users. Information relating to health and safety submitted by the home indicates that residents health and safety are protected and promoted. EVIDENCE: The registered manager has the required qualification, experience and competence to manage the home. Her knowledge in matters relating to strategic and financial planning and reviewing was sound. She was able to demonstrate that the senior staff and herself were familiar with the conditions/diseases associated with old age. Service users, staff and relatives Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 23 spoken to during the inspection confirmed that the manager was approachable, had good people skills and leads by example. There were clear lines accountability noted within the home and with any external management. Records seen indicated that the manager carries out monthly auditing of the care plans, medication administration record sheets, health and safety records and the environment. The manager said that service users views are sought and an annual survey is undertaken to ensure that the home is run in the best interests of service users. The responsible individual carries out monthly visits to comply with Regulation 26 of the Care Homes Regulations 2001 and writes a report. Eighteen comment cards were received from service users in connection with this inspection. All felt that their health care needs were properly monitored and attended to, staff respected their privacy and dignity, and the service always responded appropriately if a concern was raised. All felt that the home was always fresh and clean. The following additional comments were noted. I am very happy with the home. I am comfortable and close to my family. The home is run to a very high standard and I have no criticisms to make. Communication between the staff and the residents is wonderful they are always very helpful. The residents of Devon Lodge are usually given a choice of menu at mealtimes. The home is always kept immaculately clean in all areas including the private rooms. The residents are weighed regularly. A qualified hairdresser and chiropodist attend regularly. I would like a regular eye test to be provided for residents as it is often difficult for them to attend an eye clinic. It was noted that the home does not manage monies on behalf of service users. Information recorded in the pre-inspection questionnaire indicated that there were two service users subject to power of attorney and one subject to guardianship. Information submitted in the pre-inspection questionnaire indicated that the home has good systems in place for the regular maintenance of equipment such as fire, central heating, bath hoists and passenger lifts. The fire panel is checked weekly and unannounced fire drills are carried out monthly. The manager said that data sheets relating to COSHH (Control of Substances Hazardous to Health) solutions were kept on file. The hot water temperature was checked in two bathrooms and two service users’ bedrooms and temperatures recorded were within the appropriate range. It was noted that the fire risk assessment for the home was recently updated. Accidents and incidents sustained by service users were recorded in the accident book. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 17 X 18 3 4 X 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 3 Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 25 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. 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. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations The registered manager should ensure that a recent photograph is held on each service user file for clear identification. In the interest of safety the registered manager should ensure that medication prescribed for external use such as lotions and creams are not stored on the same shelf with oral medication. In the interest of safety the registered manager should ensure that a second person check and witness the recording of Temazepam medication in the controlled drug register when it is delivered by the pharmacy. The registered manager should review the current system in place when amending individuals’ Warfarin dosage to ensure that verbal request of change is followed up by written confirmation. The registered manager should seek the advice of a pharmacist with regard to potentially adverse reactions DS0000036052.V331003.R01.S.doc Version 5.2 Page 26 3 OP9 4 OP9 5 OP9 Devon Lodge Retirement Home 6 OP9 7 8 OP29 OP29 between food and Warfarin and that such advice is incorporated into the service user’s care plan. In the interest of safety the registered manager should ensure that handwritten entries on the medication administration record sheets be witnessed by a second member of staff whenever possible. The registered manager should ensure that recent photographs of staff members be kept on file to confirm proof of identity. The registered manager should ensure that all care staff be issued with a copy of the general social care council (GSCC) code of conduct guideline to enhance their knowledge and skills. Devon Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Lodge Retirement Home DS0000036052.V331003.R01.S.doc Version 5.2 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!