Inspection on 28/07/08 for Devonshire Court

This inspection was carried out on 28th July 2008.

CSCI found this care home to be providing an Adequate service.

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 04/05/07

Devonshire Court 17/10/05

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Devonshire Court Howdon Road Oadby Leicestershire LE2 5WQ Lead Inspector Keith Charlton Unannounced Inspection 28th July 2008 09:30 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 Devonshire Court DS0000001898.V369122.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. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 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 271 4171 0116 271 7201 bbethell@rmbi.org.uk www.rmbi.org.uk Royal Masonic Benevolent Institution Beverley Bethnell Care Home 67 Category(ies) of Dementia - over 65 years of age (67), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (67), Old age, not falling within any other category (67), Physical disability over 65 years of age (67) Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only:Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category – Code OP Physical Disability (over 65) - Code PD(E) Dementia (over 65) - Code DE(E) Mental Disorder (over 65) - Code MD(E) 2. The maximum number of service users who can be accommodated is 67. 4th May 2007 Date of last inspection 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 Leicester racecourse. It is within easy reach of the City by public transport or car. Wigston is also close by. The home is owned by the Royal Masonic Benevolent Institution (RMBI). It is a registered charity and offers accommodation to older Freemasons with nursing, residential or mental health needs. A separate unit accommodates older residents with mental heath needs. The registered provider also offers respite facilities. The home has sixty seven 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. The home has mature gardens, which include a bowling green and patio areas. The registered provider has a minibus for outside trips. Residents may use the extensive facilities, which include a functions room, hairdressing room and chapel. The registered provider has installed voice messaging lifts, specialist signs and equipment to ensure that residents needs are addressed. The weekly fees range from £471 to £743 per week - the Registered Manager Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 5 provided this information on the day of the inspection. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, newspapers, etc. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting four residents and tracking the care they received through looking at their records, discussion, where possible, with them, visitors and care staff and observation of care practices. This was an unannounced Inspection and was undertaken following concerns raised when surveys, critical of some aspects of care were received from a number of relatives – insufficient staffing, residents waiting to receive help with personal care, poor staff communication between staff and to relatives and GPs, frequency of bathing and quality of food supply - when the Annual Service Review was done in April 2008. The Registered Manager was present and helped in carrying out the inspection. Planning for the Inspection included looking at the Annual Quality Assurance Assessment completed by the Registered Manager which describes how services are provided by the home, notifications of significant events sent to the Commission for Social Care Inspection and the issues contained in the previous two Inspection Reports. There have not been any formal complaints made to the Commission for Social Care Inspection about the service since the last full inspection. There has been Safeguarding issues regarding residents monies, which needed police involvement, and there are systems in place to deal with any such reoccurrence of such issues. The Inspection took ten hours and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with five residents, four members of staff, two relatives and the Registered Manager. The inspector also took an expert by experience, someone who has experience of care services, to talk to residents and see whether they were satisfied with the home. His remarks have been incorporated into this Inspection Report. What the service does well: Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 7 There was again evidence of promoting the welfare of residents in terms of good relationships between staff and residents with staff listening and consulting with residents. Residents said that the care provided by staff was generally friendly and respectful. Residents are consulted about life at the home with residents meetings to meet their choices. There are now relatives meetings so that relatives can put forward informed suggestions to improve residents quality of life. Activities are provided as per residents preferences so that residents have lots of opportunities for various activities. A medication audit is carried out monthly to ensure residents get their prescribed medication on time. Two choices are offered for lunch every day, as per the National Minimum Standard, so that meal choice is seen to be available to residents. Facilities used by residents are odour free, comfortable and homely. Any complaints made are thoroughly investigated by the service. Staff are encouraged to have training to equip them to meet residents needs and have supervision to support them in their jobs. There has been staff training in dementia care and there is a direct line to the Organisation’s specialist worker if staff need guidance as to how to deal with any aspect of care. A Quality Assurance system is in operation that details services and identifies how they can be improved. What has improved since the last inspection? What they could do better: Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 8 All aspects of care – e.g. dates of medical checks are in assessments to assist staff to meet all residents needs, e.g. last optical check, staff need to ensure that residents health needs are covered at all times, as per contacting Medical Services if a resident has had a potentially serious injury. Staff must always treat residents with respect and the Registered Manager ensure that residents are always handled in a gentle manner when care is delivered and that their privacy and choice is always respected. The Complaints Procedure needs to be updated to state that the Social Service Department is the lead agency. Staff need to know the full Safeguarding procedure to ensure they know how to fully protect residents from abuse. There were some comments regarding how busy staff were so an increase in staffing would mean swifter care and increased supervision to be able to care for residents with increased care needs – e.g. with dementia or confusion/ residents who wander/were at risk of falls. The staff training programme is generally comprehensive though would aid staff understanding if training on all residents conditions – parkinsons disease, diabetes, strokes, hearing and sight impairments etc – were added to the programme. 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. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 9 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.V369122.R01.S.doc Version 5.2 Page 10 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): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed before admission so that staff are able to meet their needs. EVIDENCE: Residents said that someone from the home came to see them before admission to discuss their needs and they were encouraged to visit. The inspector heard the Registered Manager informing a prospective resident of this procedure when he rang up. ‘’ Someone came to see me before I came here which was good because they asked me what help I would need. I was also invited for a look around to meet the other residents’’. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 11 An assessment was inspected and it contained lots of detail of relevant information as to residents needs, as per the National Minimum Standard, which helps to ensure that all the care needs of residents is covered from day one of their admission. Residents care agreements were also seen which proved that residents were asked about their care needs. The Registered Provider said in the Annual Quality Assurance Assessment that assessments are carried out for all prospective residents as per the policy contained in information about the service and that a service users guide is provided to describe the home’s services. Assessments were seen on file – this allows staff to be aware of a new resident’s needs. The home offers intermediate care facilities for residents who want to receive rehabilitation before returning home. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents health needs are not totally covered. Medical Services are not always contacted when there is a need. Residents privacy and dignity is not always promoted. Care plans describe identified care needs to ensure relevant care is supplied by staff. Medication is suitably managed so as to protect the safety and welfare of residents. EVIDENCE: Residents spoken with said that they did not know what Care Plans were, though there was evidence on file that relatives were aware. Residents need to be reminded they can see their Care Plans and discuss them if they wish to ensure that their needs are accurately recorded. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 13 ‘’I have never heard of a Care Plan. If I wanted it I am sure they would give it to me’’. Care Plans seen by the inspector contained a good amount of information information as to the physical, social and medical needs of residents. Risk assessments were found to be a part of the plans so that staff know how to keep residents safe. Residents personal histories were noted on plans. The Registered Manager said she was planning to make this more detailed in the near future so that residents can be seen more fully as individuals with a valued history. Monthly reviews of residents needs were noted in Care Plans and were kept up to date. Staff said they had not read all the Care Plans. The Registered Manager said she would ensure that this is carried out. One staff said that a resident wore her glasses ‘sometimes’ but the Care Plan said she wore them all the time. This was inconsistent and meant that care staff may not be encouraging the resident to wear her glasses, with consequent increased risk of falls etc. Staff reading all Care Plans and ensuring this information is passed over at handovers will ensure residents always receive a service relevant to their needs. Residents said when they felt ill then staff would swiftly summon medical assistance – residents contacts with medical personnel were documented in their Care Plans. Accident records were viewed which showed that medical services were not always properly contacted on occasions when there had been a potentially serious injury, e.g. head injury - instances of falls in June 2008 for the same resident, which were not swiftly referred to Medical Services, one of whom was noted by management as an omission by staff. The Registered Manager said this issue would be followed up. The inspector and expert by experience observed that staff were friendly and respectful to residents and encouraged in a friendly manner at the residents pace. Residents said that staff respected their privacy and knocked on doors before they entered and the inspector also saw this. He observed a staff member being ‘’very patient, encouraging and enabling’’ to a resident during an activity. He also spoke to a relative who said the quality of care was very good, staff responded to the changing care needs of her mother, there was consistency of care staff and residents could choose how to live their lives. There was one instance where the inspector noted that a staff member was curt with a resident. Also that a resident’s privacy and dignity was not promoted as he sat in a state of undress with his bedroom door open when staff were assisting with personal care. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 14 A resident also said that some staff were not gentle with her when they helped her with her personal care. One resident said she was not given any sunscreen when she sat in the garden on a sunny day. This meant she was at risk from sunburn. The Registered Manager said these issues would be followed up. The Registered Manager and staff confirmed that all staff issue medication had undertaken medication training and this was recorded on staff records. Medication was observed to be properly issued by staff and signed. Medication security was followed when staff moved away from the medication trolley, as the trolley was locked. The inspector recommended that staff encourage resident to take medication when it is issued to them as it was observed that staff left it with the resident who did not take it at the time – as it may not be taken even though it has been signed for as being taken. This will then ensure that residents health needs are fully met. Medication record sheets were found to be well completed with only a small number of gaps noted. The policy of the home is that residents can handle their own medication if they are safe to do so and choose to do so. A resident spoken with appreciated that he could do this. Others appreciated staff holding their tablets and giving them at prescribed times. Medication is kept securely in medication cupboards and controlled medication kept more securely through being kept in a robust cabinet. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Residents living at the home have a high level of opportunities for activities and food is seen to be generally good. EVIDENCE: Residents said that they were generally very satisfied with the range of activities on offer and there were no comments that there should be more activities, except for a comment from a relative that there is a lack of ‘physio activities for residents unable to leave their rooms to take part in ‘armchair aerobics’ in the main area. ‘’There’s a lot going on. There is something to do every day’’. ‘’We get a list of things to do thay we can join in if we like’’ The Annual Quality Assurance Assessment said that an Activities Organiser was employed and this was confirmed by residents and staff. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 16 The minutes of Residents Meetings supported the home’s emphasis on activities. There is also a monthly newsletter which lists all the activities available inside and outside the home, which is delivered to each residents room. Residents said if they wanted to go out then the home’s minibus would take them and they could have gone shopping on the day of the inspection. The Registered Manager said that a new improved minibus was on order and that a car would be available for short trips for residents. A resident said that he could go out whenever he wanted. Another resident was seen coming back from a trip out, thereby confirming that residents have choice and independence. Records of residents meetings were seen, which happen regularly. Relatives meetings have also been set up as well to inform management as to how the home can continually promote the quality of life for residents, though this was running slightly behind schedule. The Registered Manager said another was planned to be held shortly. Some residents said they liked being outside and enjoying the garden. Staff and residents said residents can go out if they wish and are able to and attend clubs. Residents said that their visitors were made welcome by staff and this was supported by the staff comments. The inspector recommended in last year’s Inspection Report that memory boxes, containing valued items, be set up for residents, particularly for residents with dementia, so as to provide valuable reminiscence material for residents with dementia. The Registered Manager said this was still planned to be followed up. At the moment she was considering ordering a general memory box for all residents. Staff in the wing of the home for people with dementia said they had training on providing suitable activities for residents with dementia. Residents said there were no rules, e.g. going to bed and getting up times, whether to stay in their rooms or go to the lounge etc, and staff respected this, though there was one comment that a resident said she often asked to go to her room but some staff ignored her. The Registered Manager queried this but said it would be followed up with staff. Staff said that it was important that residents were able to keep their independence so they could still do things for themselves. This was confirmed by comments made by residents. Residents again said that they thought the food was good or mainly good. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 17 ‘’The food is good. We get a choice’’. ‘’I think that the food has improved. They ask us what we think of it’’. ‘’The variety is a bit monotonous at times’’. The Registered Manager said the food supply is reviewed to ensure it is of good quality. The chef told the expert by experience that the home had changed produce supplier due to qualituy problems but it was now of the highest quality. Residents said there was a choice each day for the main meals and residents knew they could ask for something else if they did not want the meal on offer. Menus showed that there was variety of food. Residents preferences were recorded in their Care Plans. Residents can have a cooked breakfast if they chose. There was evidence that food choices for a resident from a minority culture was catered for. Food records showed what variety of vegetables are offered and full food records are kept to evidence choice and variety. The food tasted was found to be of a good standard in general, though the vegetables option lacked protein, with a two course meal offered with two fresh vegetables followed by a dessert. Residents are asked their opinion of the food at their meetings, which was recorded in the notes. This gives them the opportunity to comment and the management then can change the menu accordingly as needed. One resident informed the expert by experience that portion sizes were too small at mealtimes. The Registered Manager needs to look at this issue. Menu cards are on dining room tables to supply information to residents as to the meals, which is useful to let residents know what food they are having, though large print is needed to help residents with sight difficulties. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Residents views are listened to and acted upon. The Complaints Procedure needs to be altered to make it easier to make a complaint and staff be aware of the full Safeguarding procedure. EVIDENCE: Residents spoken with thought that if there was a problem then they thought the management would sort it out: ’’I think they would do something if I complained’’. ‘’I don’t think I would ever need to complain’’. Complaints records are kept. There have been a number of complaints in the past year and there was evidence of thorough investigations of complaints on file that they had been followed up by management. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the lead Agency, the local Social Service Department, as per the National Minimum Standard. The Registered Manager said these issues would be followed up with Head Office. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 19 Staff members spoken with were aware of the procedure regarding reporting this to management but not of all the Agencies to contact if the in house arrangement failed, if abuse was witnessed or suspected. The Registered Manager said this issue would be put followed up testing staff and displaying a short procedural statement to help staff to follow the correct procedure and so be able to fully protect residents welfare if such a situation happens. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 20 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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents see facilities as homely, comfortable and odour free. EVIDENCE: Residents said that they liked the facilities of the home, that they appreciated that the home was always kept clean by staff and there were never any odours, and they could organise their bedrooms in the way they wanted. During a selective tour of the home it was observed that all areas were generally well decorated and furnished, clean, tidy and well maintained. Rooms had been personalised to accommodate personal possessions. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 21 Residents all said that they liked their bedrooms and they could bring in their own things. These were observed to be personalised and homely by the inspector, with personal items of residents furniture, pictures, photographs etc. The expert by experience said a room he had been in ‘’was exceptionally well presented’’. ‘’The bedrooms are kept nice and clean and are a good size’’. ‘’The home is kept clean and they are decorating more of it in the future’’. The lounges were comfortable and furnished in a homely fashion. The Registered Manager said that some décor had been done and there were plans to redecorate further areas and install better lighting in the dining room. Radiator guards have been fitted to radiators to minimise any risk of burning to at risk residents. The garden areas looked kept and attractive and residents said they walked there and appreciated the fresh air if they chose. There was a comment that the grass needed cutting sometimes. The Registered Manager this had been followed up. There is currently signing to the environment to assist with residents with dementia, e.g. photos on doors to make them more recognisable. The Registered Manager said that different colours are being looked at to help residents with dementia for doors, flooring etc. There was a notice of time, day, and weather in the lounge for people with dementia, which was up to date to help orientate residents. Odour control was of a good standard with no malodours, which residents positively commented on. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be further reviewed to ensure they fully meet residents needs. Recruitment procedures are in place to properly protect residents welfare. Staff training systems are in place to plan to equip staff to meet residents needs though more training on residents health conditions needs to be carried out. EVIDENCE: There were a number of comments that there were not enough staff as staff were very busy, that residents could not have more than two baths/showers a week because of this, staff did not have time to sit and chat to them and it sometimes took some time to help residents on occasion. ‘’The staff are friendly but they do seem very busy’’. ‘’If it’s an emergency they come very quickly but I have to wait if they are attending to people who need more care than me and there are quite a few here that need extra care’’. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 23 The staffing rota for the main home demonstrated that that there are normally seven to eight care staff on duty with a Senior Care Assistant and a Registered Nurse, with four waking staff at night. The Annual Quality Assurance Assessment stated that there were up to thirty residents in total who needed two staff to provide their personal care. This is a high proportion of residents with these needs. The Registered Manager agreed that staff were very busy in general. In the wing for residents with dementia there are usually three care staff on duty with one period of having two staff. There are then two waking staff at night. This wing accommodates residents with high dependency needs with the majority having periods of challenging behaviour. Meeting notes confirmed that staffing levels have increased by one staff in the morning. It was discussed with the Registered Manager that another staffing review needs to look at whether the current provision meets residents needs to see if more than the current level of staff on duty is sufficient. There is domestic cover seven days a week though this stops in the early afternoon period. It is recommended that this level of cover be reviewed so that care staff are not being called upon to carry out domestic duties, so they can concentrate on residents needs. There is a cook seven days a week, so residents nutritional needs are covered. Staff said there had been a lot training provided by the management of the home. Records seen by the inspector showed this. The Registered Manager said that there was mandatory training for staff on a range of essential care issues – e.g. food hygiene, health and safety, fire, first aid, Moving and Handling, infection control, dementia etc. There was also evidence of induction training for new staff – the Registered Manager said that the recognised Skills for Care induction pack was being used. There was also an induction checklist on staff files on essential basic care and health and safety practice. Specific training on residents conditions – e.g. stroke care, diabetes, parkinsons disease, hearing and visual impairment etc, is still needed. The Registered Manager said she has added these topics to the Training Matrix and this will be carried out in the coming months. Staff said they were encouraged to undertake National Vocational Qualification level training. The Annual Quality Assurance Assessment stated that with staff completing the National Vocational Qualification level 2 then there will be over 50 of staff with this qualification, which exceeds the National Minimum Standard. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 24 Recruitment records were inspected with Criminal Records Bureau /Protection of Vulnerable Adults checks, identification and written references in place to ensure that residents are fully protected from potentially unsuitable staff and have a proper check of competency etc. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 25 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. Management systems are in place to protect the health and safety of residents. EVIDENCE: Residents and staff said that they thought the home ran well and the management team were approachable if they needed to ask anything. Staff again said they felt valued in their work by the management of the home. ‘’The home seems to run quite smoothly’’. ‘’It seems pretty well organised here’’. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 26 The Registered Manager has a National Vocational Qualification level 4 and is a qualified nurse. There was evidence on records that staff are supervised and supported. Staff also said this was the case. One staff record showed staff had not received supervision for over five months when the National Minimum Standard is every two months. There are also regular residents meetings to ensure that there is a forum to air views and preferences, put forward suggestions etc so that residents feel they have an input into the running of the home. Staff Meetings have been regularly held and recorded so that care issues can be put to staff so that standards are high to benefit residents. A detailed Quality Assurance system was in place to review services with an analysis of questionnaires to ask residents and relatives about services on a yearly basis. It is also recommended that they are also given to other interested parties - e.g. GPs, Social Workers, District Nurses etc. The results should also be included in the Statement of Purpose so that this information is available to residents and their representatives, with an Action Plan showing how the home has dealt with any issues that arise from the survey, so that residents quality of life is shown to have been promoted. Residents monies records were found to be properly kept with running balances and two signatures had been recorded to show that transactions are witnessed with receipts available to prove that the home was keeping monies correctly. Fire Precautions: System testing was on the required monthly schedules for emergency lighting and weekly fire bell testing was also carried out. Fire drills are carried out on a basis of at least every six months. The Registered Manager is to check that this meets the expectations of the Fire Service, as they may be needed every three months. There was also a fire risk assessment on file, which helps to ensure that proper fire safety systems are in place to protect residents. Staff members were asked about the fire procedure and were aware of this. Hot water temperatures were tested by the inspector and found to be within the National Minimum Standard to ensure that residents are protected from scalding water. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 27 There is a Health and Safety folder with Risk Assessments for safe working. Window restrictors are inbuilt into all windows so that residents cannot fall out. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 28 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 2 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 2 17 X 18 2 3 X X X X X X 4 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 29 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. Standard OP8 Regulation 13 Requirement Swift access to medical services is needed if residents have significant injury, e.g. head injury, to ensure proper treatment is sought. Staffing levels need to be reviewed again to ensure that they are always able to meet residents needs. Timescale for action 28/07/08 2. OP27 18 28/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that care plans be reviewed to ensure that they are correct and followed by staff, and that staff read them so that consistent care is provided. Residents need to be always treated with respect with their rights to privacy and choice respected. DS0000001898.V369122.R01.S.doc Version 5.2 Page 30 2. OP10 Devonshire Court 3. 4. 5. OP16 OP18 OP30 The Complaints Procedure needs to be changed to indicate who the Lead Agency now is. Staff need to be aware of the full Vulnerable Adults procedure. Staff training on all relevant issues needs to be supplied to make sure staff are fully aware of residents needs. Devonshire Court DS0000001898.V369122.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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