Inspection on 17/10/05 for Devonshire Court

This inspection was carried out on 17th October 2005.

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

Devonshire Court 28/07/08

Devonshire Court 04/05/07

Devonshire Court 16/06/05

Devonshire Court 04/11/04

Devonshire Court 24/05/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Devonshire Court Howdon Road Oadby Leicestershire LE2 5WQ Lead Inspector Mrs Gillian Adkin Unannounced Inspection 09:30 17 October 2005 th 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 Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 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. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Devonshire Court Address Howdon Road Oadby Leicestershire LE2 5WQ 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) 0116 2714171 0116 2717201 arichards@rmbi.org.uk Royal Masonic Benevolent Institution Mrs Anthea Mary Richards Care Home 59 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (59), Physical disability over 65 years of age (59) Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers. No person may be admitted to the home who falls within categories MD(E) or DE(E) when 10 persons in total of these categories/combined categories are already accommodated within the home. Date of last inspection 16th June 2005 Brief Description of the Service: Devonshire Court is a large traditional care home built on a four and a half acre site. Built in 1966 and situated on the outskirts of the City of Leicester and in the residential area of Oadby, the home is close to the famous Leicester racecourse. It is within easy reach of the City by public transport or car. Wigston is also close by. The home was opened by the Queen Mother in 1966 and is owned by the Royal Masonic Benevolent Institution (RMBI). The home is a registered charity and offers accommodation to for up to fifty-nine service users who are elder Freemasons with nursing, residential or mental health needs. A separate unit accommodates the elderly mentally frail service users. The registered provider also offers respite facilities. The home has the following categories of registration Dementia - Mental Disorder, excluding learning disability or Old age Physical disability over 65 years of age The home has fifty nine single en suite bedrooms.Internal communal facilities include one large lounge and several quiet lounges on each floor. There are also two conservatories giving access to the patio area.A communal dining area is on the ground floor.Set in four and a half acres of land the home has mature gardens, which include a bowling green and patio areas. The registered provider has a minibus for external trips. Service users may use the extensive facilities, which include a functions room, billiards room, hairdressing room and chapel. The registered provider has installed voice messaging lifts, specialist signs and equipment to ensure that service users needs are fully addressed.The home is currently undergoing development to include eight new bedrooms and a new reception area. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over one day and commenced at 9.30.00 am on 17/10/05.The inspection took 7.5 hours. The deputy care manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through review of their records, discussion with them, and their relatives, care staff and observation of care practices. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. During this inspection a tour of the accommodation occupied by those case tracked took place and the inspector viewed internal records, and care plans. The inspector spoke to residents, nurses, care and ancillary staff. One relative was spoken with during this inspection. There were 58 service users accommodated at the time of this inspection of which most had been assessed as having high /medium dependency needs. Comments were received from a number of residents including those selected for case tracking. Comments made by residents about the service were mostly positive. Typical comments included: “Staff ask my opinion and if I am satisfied” “I am aware that I have to stay in my room when the fire alarm goes off” “I have not seen my care plan” “I think they are a bit short of staff sometimes” “Rooms are very comfortable and warm” “I like my own company and choose not to attend activities provided” “I like to have a bath or shower as often as possible” “Staff help me with my medication” “I have been given a pendant to call staff I wear it round my neck” “I have brought some of my own things into the home” “ Managers are very supportive-on the ball” Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 7 To improve the outcomes for residents more frequent bedrail maintenance checks could be undertaken and following any incidents relating to use of bedrails the risk assessment should be up dated immediately. Where residents are at risk nutritionally risk assessments should be evaluated a least monthly along with the care plan. Moving and handling risk assessments should fully include use of slings and their contra-indications to other equipment being used. 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. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 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 Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents are assessed by the care manager prior to moving into the home, this results in them being assured their needs can be met. EVIDENCE: Three residents were selected for case tracking. All of the care records included all relevant assessment information including risk assessments, and evidenced subsequent care reviews. Care needs were fully represented in care plans. One service user stated that the manager “came to see me in hospital” Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9. Resident’s healthcare needs are met by the provision of a robust care plan. Outcomes would be further improved by; more frequent evaluation of risk assessments and more involvement by care staff in the care planning process. EVIDENCE: Care plans for three service users were inspected; these appeared to address all assessed needs. Care plans tracked were evaluated by trained staff however this was not done on a monthly basis as would be considered good practise. In one instance evaluation did not fully reflect of outcomes of care delivered and the current situation with regard to residents mobility. Assessments were in place for the risk of falls, nutrition and for developing pressure sores. Records were seen of GP and community nurse visits and input. Information recorded in care plans regarding equipment was accurate and staff spoken with were aware of this. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 11 It was noted however that a resident who was being transferred by staff had a sling, which was left in place after the manoeuvre had been completed. Staff when questioned indicated that this was usual practise and were unsure if this was correct procedure, stating that they would be informed of any changes by trained staff. It was recommended that advice be sought from an appropriate external professional. This was done immediately by the care manager and action taken in accordance with advice given. Personal choices were recorded in care plans and reflected during conversation with service users tracked. Administration records for the three case tracked residents were seen and appeared to be in good order. Discussion with staff demonstrated that they were fully aware of care needs and were kept up to date by trained staff at handovers. One member of staff stated that if they needed to know anything they would look at the care plan. Residents spoken with said that staff administered their medication accurately and on time. One resident informed the inspector that she required help with an inhaler and evidence was seen of an assessment, which had been completed by the care manager for this. Qualified nurses and trained care assistants administer medication; the care manager assesses their competency, Medicines related to those service users tracked had been appropriately administered and records seen were well maintained. One residents tracked required the use of oxygen and this was documented on medication records and in the care plan. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 12 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 The lifestyle experienced and the ability to maintain essential links is achieved by flexible routines and an excellent programme of activities. This ensures that resident’s needs and preferences are considered and results in a fulfilling lifestyle. EVIDENCE: One of the residents case tracked were able to voice their opinions regarding the lifestyle they experienced in the home. This resident had recently been admitted and therefore was only able to give a limited view. The service user indicated that since her arrival she considered the staff to be “very good” she also stated “Staff are very respectful and respect my privacy” Discussions with other residents indicated that they were happy and content with the systems and routines of the home. The activities programme is on display in the foyer and on the notice board in the EMF unit this details weekly activities Staff in this unit indicated that they are sufficiently well staffed to undertake activities with those residents accommodated in this unit. Two service users spoken voiced their opinions about activities and both indicated that they preferred not to take part. Residents’ were observed during a game of bowls. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 13 A monthly news brochure is produced and distributed to all residents, which details activities planned, external trips and religious services. Residents are also kept informed by way of a RMBI newsletter produced quarterly. The routines and activities provided within the home meet service users’ expectations, interests and needs. Work undertaken by staff to achieve this outcome must be recognised as strength in the home’s performance. Residents are able to maintain links with family, friends and community within the routines and activities provided. Staff commented that they considered residents to “have a good quality of life” Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 14 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 the possibility of abuse by robust policies, staff training and regular monitoring of those considered to be at significant risk. EVIDENCE: Robust adult protection policies and procedures are in place, which are included in the initial induction and foundation programme for staff. When questioned about reporting alleged abuse, a new member of staff was able to verbally demonstrate that she was aware of the whistle blowing policy and procedure. A member of staff spoken with regarding a residents who was tracked indicated that accidental abuse can occur particular when using equipment such as bedrails however staff are vigilant and monitor residents frequently recording their visits on care records. Records of visits by staff to the resident were available in the resident’s room. It was noted that a risk assessment had been put in place in one of the residents care plan (tracked) following a POVA investigation, to identify the significant vulnerability of the resident. Staff had been made aware to perform personal care in two’s Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 15 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): 19 The home is clean, comfortable and premises are well maintained resulting in a suitable and safe living environment for residents. EVIDENCE: The accommodation of those residents tracked was inspected and appeared to be comfortable, homely and satisfactorily maintained. Communal areas were clean and tidy although some corridors required minor decoration to paintwork. Furniture and fixtures were in good condition and appropriate to the needs of the residents tracked. Discussion with a new resident indicated that they had been able to bring some personal items into the home on admission. This included a resident with sensory issues who brought in a talking clock. Observation of maintenance records demonstrated that: Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 16 A team of maintenance personnel are employed by the RMBI and a maintenance plan was seen for 2005. Phase one of the plan had been completed in September 2005. This included all essential servicing and testing of systems and equipment. Residents had been appraised of the status of the building work. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 17 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): 27.29.30 The needs of residents are safely met by thorough a robust recruitment and selection process and adequate numbers of suitably skilled and well-trained staff. EVIDENCE: Inspection and calculation of staff rosters demonstrate that staffing levels and hours provided meet with the recommended guidelines of the previous registration authority and are in line with recommended Residential Forum Guidance. Internal records demonstrate that the home has experienced a high level of staff leaving their employment and discussions with the care manager indicated that there is an ongoing recruitment programme. Shift gaps are being filled with agency staff. Two of the three residents tracked were assessed with high dependency needs. All information identified in care plans and received from residents during the inspection indicated that staffing levels were adequate to meet their needs. No concerns were raised from any parties regarding current staffing levels other than staff who commented that they would like more time to spend with their key residents on a one to one basis. . The skill mix of staff identified on duty rosters appeared to be appropriate to meet the needs of residents in occupancy at this inspection. Staff files were inspected on this occasion and all essential documentation was in place. . Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 18 Documentation supplied by the home indicates that staff have received all essential training including TOPSS foundation induction and adult protection. Future training planned includes NVQ level 2.3.4 and first aid plus health and safety. Currently the home has achieved 69 of staff with NVQ level 2 and records seen indicate that by October 2005, 81 of staff will have an NVQ qualification. Two senior staff are undertaking their NVQ level 4 in care/management. This is considered to be an exceptional achievement and is to be commended. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 19 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): 32.38 The health, safety and welfare of service users are protected by systems and procedures being in place. The home is run to ensure that the best interests of service users are safeguarded. EVIDENCE: The manager of the home is a qualified nurse and has many years management experience. Staff spoken with felt supported by the management team and confirmed that staff meetings are regularly held. The manager said that she routinely walks about the home to chat to residents and give them the opportunity to express views. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 20 Observation of the premises and inspection of internal documentation demonstrated that the home was well maintained. Documentation supplied by the registered manager indicated that all other routine maintenance had been completed as per RMBI procedure and was not therefore inspected. All staff spoken with including a new staff member had received (or were due to receive) manual handling training during their induction; moving and handling practises were observed and appeared to be safe. Concerns were raised regarding the frequency of bedrail maintenance particularly following a particular incident which had occurred and resulted in an injury to the resident (tracked) No records were available at this inspection to clarify how often the maintenance was carried out and the risk assessment in the residents care plan had not been updated following then incident. Staff and service users appeared to be aware of fire procedure. Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 21 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Devonshire Court DS0000001898.V252824.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Where a resident requires the use of pressure relieving equipment (cushions) the home must seek appropriate advice regarding the use of a sling in particularly where the sling is to be left in place for extended periods of time (to establish any contra-indications). Timescale for action 17/11/05 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 4 Refer to Standard OP7 OP3 OP38 OP7 Good Practice Recommendations It is recommended that care plans be audited randomly by the care manager to ensure they are reflective of the current situation. It is recommended that pressure sore and nutritional risk assessments are evaluated at least monthly where the resident is assessed as at risk. It is recommended that maintenance checks on bedrails be undertaken at least monthly. It is recommended that care staff have a more in depth role in the care planning and evaluation process to ensure they are fully appraised of needs. DS0000001898.V252824.R01.S.doc Version 5.0 Page 23 Devonshire Court Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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