Inspection on 08/10/07 for Devonia House Nursing Home

This inspection was carried out on 8th October 2007.

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

Devonia House Nursing Home 13/09/06

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Devonia House Nursing Home Leg O`Mutton Corner Yelverton Devon PL20 6DJ Lead Inspector Andy Towse Unannounced Inspection 8th October 2007 08:50 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 Devonia House Nursing Home DS0000067360.V342803.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. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Devonia House Nursing Home Address Leg O`Mutton Corner Yelverton Devon PL20 6DJ 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) 01822 852081 01822 852081 Mr Anthony John Bloom Miss Jean Sherriff Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (10), Physical disability over 65 years of age of places (32) Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for a maximum of 32 service users in the category Physical Disability over 65 years PD(E) Registered for a maximum of 10 service users in the category Old age OP 13th September 2006 Date of last inspection Brief Description of the Service: Devonia House is a converted Victorian house situated in the rural village of Yelverton. The home is on the edge of Dartmoor National Park. Yelverton village is within walking distance of Devonia House and has a church, newsagents, post office and bank. There is a bus stop nearby which has routes to Tavistock (4 miles) and Plymouth (10 miles). The home has been owned by Mr and Mrs Bloom since 1992 and Managed by the same registered Nurse - Jean Sherriff since 1987. The home is registered for 32 Service Users of either gender over the age of 65 who require nursing and/or personal care. Accommodation is presented on 2 floors with level access to most of the rooms. It provides 23 single rooms, 17 with en-suite facilities, 4 double rooms all with en- suite. There is a dining / lounge area and one smaller lounge. The home has well-maintained gardens and some of the rooms are afforded scenic views over Dartmoor and Walkham Valley. Devonia House Nursing Home DS0000067360.V342803.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 which took place over a period of ten hours. The inspection included a tour of the home, during which time all communal areas were seen and some, but not all bedrooms. The personal files of three residents were inspected as were the files of two staff members. We spoke with eight residents, four staff, three visitors, and the registered manager. In addition to this, information was obtained from surveys forwarded to ten relatives and ten residents. Eight relatives responded to these surveys and five residents. The registered manger also compiled an assessment form prior to the inspection and healthcare professionals were contacted over the telephone regarding how they regarded the home. What the service does well: The home operates a safe admissions procedure which ensures that only those people whose needs can be met are admitted to the home. This is accomplished by the manager visiting prospective residents and assessing their needs prior to admission as well as obtaining relevant information from other professionals. Records and communication with healthcare professionals shows that the healthcare needs of those resident at Devonia House are met, that medication is stored and administered appropriately and there are good relationshi[ps with healthcare professionals. People living at Devonia House are encouraged to maintain contact with family and friends. Throughout the inspection there was a constant coming and going of visitors. They were clearly at ease and confirmed that they were free to visit the home at any time. They were seen to be made very welcome by the registered manger who appeared to be on good terms with all those seen visiting the home. Residents and relatives knew how to make a complaint. Residents considered that the registered manger was very approachable and this was borne out by observations during the day. Residents receive a varied diet which the matron amends to reflect the preferences of residents. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 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 Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Quality in this outcome area is good. The admissions process ensures that only residents whose needs can be met are admitted to the home. In order that they can make an informed choice about visiting the home prospective residents and their relatives can visit the home as part of the admissions process. The home does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 9 We examined the personal files of three most recently admitted residents. Records on these files showed that the registered manager had carried out visits to the prospective residents prior their admission. As part of these visits she had obtained information which had been recorded in a care needs summary. This enabled her to assess whether her home would be able to meet the prospective resident’s needs. Whilst none of the residents whose files were examined had actually visited the home prior to being admitted, the home had been visited by their relatives who then made decisions on the prospective residents’ behalf about whether it would be suitable to meet their needs. Written feedback from five residents showed that they considered that they had received enough information about the home for them to decide whether it was suitable to meet their needs. The home also has a policy regarding emergency admissions which requires that an assessment is carried out within 48 hours of an admission to ensure that residents are being offered care which meets their needs as soon as is possible. Devonia House does not offer intermediate care. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Residents benefit from well written care plans and a service which meets their individual needs. Residents receive a good standard of health care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The personal files of three residents were examined. All contained care plans. The care plans contained details of the individual person’s needs under headings such as, Hygiene and Dressing, Skin Integrity, Eating and Drinking, Communication, Mobilisation and Wound Care. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 11 There was the provision on each care plan for either the resident or their relatives to sign to acknowledge their agreement to the contents contained in the document. One relative had signed the plan with the comments, ‘not bad’ and another plan had been signed by the person’s daughter. Some plans were seen not to have been signed, however this was resolved on the day of the inspection when the plans were taken to residents who then signed them. The home’s written policies show that the home encourages relatives to be involved in the care of those resident in the home when it states, ‘family are welcome and encouraged to discuss the care of the patient with the matron and staff.’ The home has appropriate provision to meet the needs of those who reside there. There are various specialist mattresses to ensure the tissue viability of residents and entries on files showed that there is regular contact with community nurses and general practitioners in accordance with the individual needs of residents. Responses from healthcare professionals to the surveys forwarded prior to the inspection received comments confirming that the staff team worked closely with the community nurses in delivering palliative and terminal care and that the home contacted healthcare professionals to seek advice if required. Healthcare professionals considered the registered manager knowledgeable and had confidence in her. The files of three residents were examined. From entries on the files it was seen that in instances where residents required personal care, instructions were clearly written regarding how this was to be carried out. These instructions related to how that resident wanted his/her personal care carried out, whilst still maintaining the persons right to independence and dignity by ensuring they did as much of their personal care as they could or wanted to. Staff were seen to treat residents with respect, addressing them by the name or title they preferred and knocking on bedroom doors before entering. Other instructions on care plans showed deference to their needs, such as, with regard to communication being, ‘patient, reassuring and tactful’ and ‘speak clearly, face to face and slowly.’ In the case of another resident, ensuring that this person’s preference for routine was adhered to. All files were seen to contain a record sheet. These were written up at least twice every day and sometimes more frequently dependent upon what was happening in a resident’s life and changes in their needs. All residents’ files contained Waterlow Assessments . These are assessments of each resident’s level of ability, which can be used in drawing up care plans and in monitoring the changing needs of each person. The medication policy used by the home is the one compiled by the South and West Devon Health Authority in 1998. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 12 Medication was seen to be kept securely. There is a lockable trolley which is secured to the wall. Other medication is kept in a lockable medicine cabinet within a locked room. Controlled drugs are kept securely and appropriately. Their administration is recorded correctly with double signatures and a counting of stock. The home has two fridges where medication requiring cool temperatures is kept. Record is kept of the opening date of such medication. In recording the administration of medication, appropriate records are kept regarding such instances as the refusal of a resident to take medication. A written record is kept of all medicines which are sent for disposal. Only registered nurses take responsibility for the administration of medicines. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is good. Whilst the home does not offer a wide variety of activities, those available suit those who reside at the home, many of whom prefer to follow their own interests. Residents benefit from the home’s policy of ensuring that visitors are made welcome. Residents enjoy a varied menu. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In previous inspections reference has been made to activities available within Devonia House. Discussion with residents confirmed that they were generally quite satisfied with what was available at the home. There were considerable Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 14 numbers of board games stacked in the dining room but those asked were not interested in such activities. Responses from the five residents who responded to the survey ranged from two who ticked the boxes indicating that there were ‘usually’ or ‘sometimes’ activities arranged by the home that they could take part in’, through to comments such as, ‘l am quite content being in my room but activities are available if l require them’, ‘this is not one of my requirements’, and ‘I have no wish to take part in any activities.’ The home however does, on residents’ files, keep a list of what their interests are and there were instances where it was shown that these had been pursued. One resident who likes horses had a relative bring a horse to the home and another resident was seen in his/her room reading specialist books which his/her file had identified as being of special interest to him/her. During the course of the inspection there was a constant coming and going of visitors. This was in accordance with the home’s Statement of Purpose which states that visitors are welcome. All spoken to confirmed that they could visit at any time and were made welcome. One has brought along a pair of gun dogs, which her relative and other residents liked to see. All the visitors spoke highly of the home and were seen to be on very good terms with the registered manager. Entries on files showed that residents were free to live their lives with as much independence as they were able to manage. One file referred to a resident enjoying visiting local shops, sitting in the garden and having a ‘great interest in art, especially sketching and painting’. Residents rooms contained ornaments and often paintings which were of important sentimental value to them and/or reflected their earlier life, or interests. Some residents had also brought with them items of furniture. Residents were seen to enjoy their dinner. Several chose to eat in their rooms. Those eating in the dining room were seen to enjoy a meal eaten in a leisurely manner. This was borne out from discussion with residents who were positive about the food they received at the home and also from entries on their files which contained information about their likes and dislikes. Responses from the five surveys returned by residents, showed that three ‘always’ liked the food in the home and two ‘usually’ liked it. There were also comments such as ‘on the whole the meals are good and acceptable.’ The menus are prepared by one of the owners and where necessary are amended by the registered manager to suit the preferences of the residents. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is good. People who live at Devonia House are confident in approaching the management if they have any concerns or complaints. The manager’s regular contact with people who live at Devonia House enables them to discuss any issues they have directly with her. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure is referred to in the Service User Guide where it states that any complaint ‘will be listened to and acted on.’ Copies of the written complaints procedure are issued to residents and their relatives upon admission to the home. The registered manager sees and speaks with every resident every day. This gives them the opportunity to discuss with her any complaints or concerns they may have. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 16 Residents spoken to said that they would see the manager if they had any complaints or concerns. All five residents who responsed to the pre inspection survey said that they knew how to make a complaint. They all said they knew who to speak to if they were not happy, with one adding with regard to this, ‘the matron or under matron calls in every day and are always available in the building by day.’ The manager also keeps a book which details all the complaints made and what action has been taken regarding them. This showed that residents had the confidence to make complaints and that the manager took these seriously and took relevant action, including, where appropriate, apologising and monitoring service delivery to ensure a resident’s comfort was ensured. Whilst at the start of the inspection the home’s complaints procedure did not include the right of those making the complaint to contact the Commission for Social Care Inspection (CSCI) at any stage of the complaints process, this was brought to the manager’s attention and the procedure was amended during the course of the inspection. We had a general discussion with members of staff. They were able to give examples of what constituted abuse and what action to take if they thought it was occuring in the home. The manger had arranged for the staff to participate in Protection of Vulnerable Adults (POVA) training however this had had to be cancelled due to staff sickness and the manager will re arrange this. This will ensure that all staff are knowledgeable about what constitutes abuse and what to do if they suspect that it is occurring. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good. Whilst the home in general is adequately maintained, the carpet in the landing areas needs attention. The home has a good standard of hygiene and cleanliness. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection we walked around the premises and as well as seeing the communal, kitchen, Laundry and bath areas, we also went into the bedrooms and spoke with several people who live there. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 18 Whilst in general the home appears to be well maintained, the carpet in many areas was seen to be worn and in some places coming away from floor fixtures to an extend whereby if it is not either replaced or refitted it will consistute a safety hazard for those who live and work in the home. Since the last inspection, as recommended, the carpet has been replaced and the washing machine which was seen to be out of order has been replaced. At the entrance to the laundry is a steep step above which is a notice warning those entering of its existence, however this room can be accessed directly from a thoroughfare used by residents. This was discussed with the registered manager. The home itself appeared well equipped to meet the needs of those who live there who have needs identified with moving and handing and requiring assistance with bathing . The communal areas were seen to be clean and well maintained. Bedrooms were seen to have been personalised with residents having the opportunity of bringing in items of furniture, ornaments, pictures or other items of sentimental value. Many bedrooms had good views of the surrounding countryside. Residents spoken to said that they liked their rooms. Externally the home has well maintained and pleasant garden areas. These can be accessed by residents. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. There are sufficient staff with the skills and experience to meet the needs of residents. Residents are protected by an appropriate recruitment procedure. The home has a commitment to NVQ training and the manager will ensure that staff receive appropriate training in mandatory subjects. This judgement has been made using available evidence including a visit to this service EVIDENCE: The rota was made available. This showed that between 8 am and 2pm there were six care staff on duty including one registered nurse, who might be the manager, between 2pm and 5pm, four or five care staff including a registered nurse and between 5pm and 8pm, four care staff including a registered nurse. Staffing at night usually comprises three staff one of whom is a registered nurse. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 20 We were informed that there had recently been staff shortages which had resulted in existing staff working additional hours and also agency staff being used. The manager was recruiting new staff in order to reduce the dependency on existing staff working additional hours or the increased use of agency staff. Examination of staff files showed that the home had a good recruitment procedure. The files examined contained two references and required items confirming the identity of the staff member. All files contained police checks and examination of start dates showed that no staff had commenced employment prior to the home having checked that their names were not included on the Protection of Vulnerable Adults (POVA) register. This procedure ensures that residents are not put at risk as only staff suitable to work with vulnerable adults are employed at the home. New staff were seen to participate on an induction which uses the ‘Your Induction to Work in Social Care,’ compiled by what was the TOPPS organisation. There is a commitment to staff participating on NVQ training courses. Of the eleven care staff, six have NVQ 2, one has NVQ 3 and another two are considered, by the manager, as ‘likely’ to start this training. This will result in the home having a high number of care staff with this recommended qualification in care. Records of training which were made available showed that since the last inspection staff had received training in fire safety, basic food hygiene and continence care with the registered manager planning training relating to moving and handling and the protection of vulnerable adults. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 21 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 and 38 Quality in this outcome area is good. The registered manager is competent to run a residential care home. Whilst the home does not take responsibility for looking after the money of any of those who reside in the home, it operates a safe and secure system for safeguarding any valuables it holds on behalf of residents. Quality assurance systems are informal and would benefit from being formalised and recorded. Whilst the registered manager has confirmed that issues relating to health and safety are in order, it would be beneficial if all documentation regarding this is kept in the office for inspection and for access by the registered manager. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 22 This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has considerable nursing and managerial experience much of which was gained prior to her becoming manager of Devonia House in 1987. Responses from healthcare professionals prior to the inspection spoke of ‘people having confidence in her’ and that she was ‘knowledgeable’. Whilst managing the home she also keeps in close contact with the residents of the home, doing a ‘round’ every morning and seeing each resident individually. As stated in the previous inspection, the registered manager’s practice of seeing all residents individually on a daily basis, is an informal system of quality assurance. Discussion with residents and relatives confirmed that this informal process is the main system of quality assurance within Devonia House. There was discussion at the previous inspection with regard to the registered manager introducing a questionnaire for residents regarding their satisfaction with the service as part of a more formal quality self assessment system. However the manager has yet to introduce a formal system of quality assurance. We were informed by the registered manager that residents of Devonia House manage their own personal money. In instances where residents are unable to manage their own finances, this responsibility is then taken on by their family or representatives. Valuables held by the home on behalf of residents were seen to be appropriately recorded and securely stored. Health and Safety issues were discussed with the registered manager and relevant documentation requested. Documentation made available showed that fire safety equipment was regularly tested and serviced appropriately. That accidents were recorded with details of remedial action taken to ensure the safety of residents. Details regarding the testing of electrical installations within the home and the testing of portable electrical appliances were not available at the time of the inspection as we were informed that these were kept by the provider. Since the inspection we have had further discussions with the registered manager who informs us that the home now has certification to state that the electrical installations within the home are safe. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 23 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 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 2 X X X X X 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 2 X 3 x X 2 Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 24 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. 1 OP19 Standard Regulation 13(4)(a) Requirement That a risk assessment is carried out regarding the entrance to the laundry and that should this be then regarded as a potential hazard to residents, appropriate action is taken to ensure their safety. Timescale for action 30/11/07 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. 3. OP38 Refer to Standard OP19 OP33 Good Practice Recommendations It is recommended that the carpet in the hallways of the home is either refitted or replaced before it becomes a safety hazard to staff and those who live in the home. Systems of quality assurance should be formalised. Records should be kept in the office so that they are available for inspection. Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Devonia House Nursing Home DS0000067360.V342803.R01.S.doc Version 5.2 Page 26 - 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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