Inspection on 04/05/07 for Devonshire Court

This inspection was carried out on 4th May 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

Devonshire Court 28/07/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Devonshire Court Howdon Road Oadby Leicestershire LE2 5WQ Lead Inspector Keith Charlton Key Unannounced Inspection 4th May 2007 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.V327447.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.V327447.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 2714171 0116 2717201 bbethell@rmbi.org.uk www.rmbi.org.uk Royal Masonic Benevolent Institution Beverely Bethell Care Home 67 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 (67), Physical disability over 65 years of age (67) Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 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 October 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 is owned by the Royal Masonic Benevolent Institution (RMBI). It is a registered charity and offers accommodation to elder 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 home has undergone development to include eight new bedrooms and a new reception area. The weekly fees range from £453 to £705 per week - this information was provided on the Pre Inspection Questionnaire, that the Registered Manager completed prior to the inspection. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, newspapers, etc. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was on duty. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report. There has been one complaint made to the Commission for Social Care Inspection since the last inspection, which was investigated by the Responsible Individual. There was no evidence found to support the complaint. The Inspection took place between 9.30 and 16.00 and included a selected tour of the home, inspection of records and direct and indirect observation of care practices. The Inspector spoke with twelve service users, five staff members, and one relative. The Inspection was concluded the following week with the Registered Manager. What the service does well: Residents said that staff were friendly and helpful towards them, reported that staff welcome visitors and they generally thought the food provided to them was of a good standard. Staff were observed to be generally friendly towards residents. Residents said they were comfortable with raising any concerns that they might have and were satisfied that the concerns would be listened to and acted on by staff and management. Detailed records are made of complaints and any follow up action needed. There are flexible visiting arrangements in the home and relatives and visitors are made welcome. Residents said they were provided with a service users guide to the services the home offers which was useful to them. Staff said they were to be trained on how to provide suitable activities for residents with dementia, so as to provide proper stimulation and interest. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 6 Residents generally spoke positively about the activities arranged by staff, which provided interest and stimulation for them. There is an excellent booklet produced by the home, which outlines the activities that are offered. Staff thought they were valued in their performance of their jobs and staff training is encouraged by the Registered Manager in order to equip staff to meet residents needs. The Registered Manager has a positive attitude in seeking to improve the care standards in the service and was receptive to ideas as how to improve the service for residents. What has improved since the last inspection? What they could do better: The Registered Provider needs to ensure that the welfare of residents is protected at all times regarding medical authorities being involved where necessary following injury. Care Plans need to contain more detailed information as to the past life history of residents /their representatives agree to supply this information. This helps staff see service users as people with a valued past and assists in talking with them. A record of daily living choices is recommended to be part of the Care Plan so that residents individual wishes are followed. Care Plans are recommended to be reviewed so that staff can consider what action is needed to help residents, and acting on information gathered. Medication systems need to be reviewed so that it is recorded as to how to properly supply all medication to residents and creams are initialled to be able to track who administered the cream. As the home accommodates a significant number of residents with mental heath needs, staff need be trained in dementia care. Staff must always be aware of residents care needs: Providing more colour signs to Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 7 toilets/bathrooms would assist residents who have dementia, in that they can identify facilities clearly. Also to set up memory boxes for residents with dementia, which can be used for reminiscence and interest for them. The food provided to residents needs to be reviewed to ensure that it is always tasty, that there is a larger choice for residents with more diverse needs and more choice for the breakfast menu. As there were comments received about staffing levels being too low there needs to be a review to ensure levels meet residents needs, and for the Registered Manager to take action to secure more volunteers to spend time chatting to residents. There needs to be a more thorough review of safe working practices, including the need to protect residents from hot water temperatures and ensuring a detailed fire risk assessment is in place, with regular unannounced fire drills to ensure staff follow the proper procedure if a fire were to break out. Lifts need to be reviewed to ascertain they are fit for purpose as they have broken down in the past year, thereby causing inconvenience for residents. 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.V327447.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is well managed and meets the needs of residents. EVIDENCE: Residents said that they could visit the home prior to their admission by way of a trial period, to give them a good idea of what services the home offered. They said they were asked about their needs so that staff could care for them properly. Some residents said they were provided with a service users guide to the services the home offers which was a useful guide for them. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 10 There was evidence of assessments undertaken by management available on the residents files examined by the inspector. This incorporates most of the issues contained in the National Minimum Standard, to ensure staff can meet the individual needs of the new resident. The home offers intermediate care facilities for residents who want to receive rehabilitation before returning home. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans describe identified care needs to ensure proper care is supplied by staff. Medication is generally suitably managed so as to protect the safety and welfare of service users. EVIDENCE: Some residents asked knew they had a Care Plan and that they had been involved in this being set up, which helps to ensure that residents needs are met. If a resident cannot do this then a relative is involved instead to ensure there is information as to that resident’s needs. Relatives signatures were on plans to evidence this took place. Residents needs were seen to be detailed by the inspector in their Care Plans and all residents case tracked had a plan of care in place. The registered Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 12 manager stated that care plans are reviewed monthly and this was seen as recorded in the Plans. Risk assessments also form part of Plans to reduce the risk of harm from identified risks. Some Care Plans did not clearly set out some medical checks, e.g. dental needs as regards routine dental checks, the last optical test or whether the residents needed a regular chiropody visit. The Registered Manager said this issue would be put in place. It was recommended that more detailed residents personal histories be compiled so that they can be seen more fully as individuals with a valued history. The Registered Manager said she had identified this aspect and was planning to implement this in the near future. Care Plans are recommended to be reviewed so that staff can consider what action is needed to help residents, e.g. if a resident has constipation to consider their diet to assist them to deal with this, and acting on information gathered, e.g. contact with the dietician if there is weight loss. Residents said that if there was a medical problem then staff would call a GP to see them. Accident records were viewed. The GP was not always appropriately called if there had been potentially serious injuries, e.g. a head injury. The Registered Manager said that she would ensure this area of practice is changed in the future. Residents generally said that staff and the manager were friendly. Residents said that staff respected their privacy and knocked on doors before they entered. The inspector observed that staff were largely very friendly and respectful and carried out tasks at residents pace. There was one instance where a care staff appeared over enthusiastic in participating in a balloon game with some residents and did not ask a resident if she wanted to join in but assumed this would be ok, without checking with the resident first. The Registered Manager said she would follow this up to ensure residents are always treated in a dignified manner. The medication system was inspected and was found to be generally well managed with medication appropriately administered. There have been a number of instances in the past year where medication was not issued properly so the Registered Manager set up a system to audit medication on a monthly basis to ensure the health and safety of residents. The inspector also recommended that new staff be mentored for an initial period to fully ensure they know how to follow the proper procedure. The Registered Manager and staff confirmed that only trained staff issue medication. Medication recording was generally complete with few gaps observed. Medication is securely kept in a locked trolley. The administration of creams needs to be initialled, not ticked, so as to locate who carried this out in case of the need to track this, and ‘as directed’ medication needs to be clearly Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 13 stated so that staff are clear as to what needs to be given to residents. The Registered Manager said these issues would be put in place. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to lead full lifestyle and can exercise choice. Food choices need to be extended to ensure that all residents needs are covered. EVIDENCE: Residents said that there was a wide range of activities and all said this was at a good frequency. The home publishes a monthly diary of activities that residents can participate in if they choose. This is a very well set out document and provides detailed information for residents. This situation is commended. Residents also said they are not forced to be involved in activities. Residents said if they wanted to go out then the home’s minibus would take them and a number had gone to the theatre recently. A resident said that he went out to his weekly club and used two buses to get there and he liked this Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 15 independence. Another resident was seen coming back from shopping at a local shop. Records of residents meetings were seen. The inspector recommended that these meetings be more regular and that relatives meetings be set up as well to inform management as to how the home can continually promote the quality of life for residents. The inspector recommended 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. Staff said they would soon be having training on providing suitable activities for residents with dementia. Residents said that there were no rules that they knew of, e.g. no one reported that there were set going to bed and rising times, and all thought the atmosphere of the home was friendly and relaxed. A resident said he was given the choice of keeping his medication, which he liked as it helped him to retain his independence. This situation is commended. Residents also spoke of being able to maintain their independence in other ways - walking in the large grounds of the home, and one resident said there was an opportunity to do gardening. This situation is commended. Inspection of residents accommodation demonstrated that they were able to bring in to the home their personal possessions. Residents confirmed this. Personal choices were not always identified in individual care plans. It is recommended that this is included during the assessment of potential residents and a record of daily living choices is part of the Care Plan. The Registered Manager said this would be carried out Both residents and relatives stated that visitors are always welcomed to the home and no one reported any restrictions. The visitor spoken to was very impressed with the standard of care provided by the staff to her mother and the way they had helped her father in the past. There were generally positive views regarding the food though there were some concerns received regarding that food could sometimes be lukewarm, and that breakfast choices were more limited than in the past, as a resident said it would be nice to be able to have bacon and egg every day. The vegetarian choice on the menu needs to be recorded so that the range of choices can be checked. A resident from a minority community did not have all his dietary needs met. The Registered Manager said these issues would be put in place. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 16 The food tasted and was found to be generally well cooked and had flavour, though this could be more enhanced. There were set choices to the main meal on five days a week and other options available for the other two days if a residents did not want the roast meat dish. It is also recommended that a menu board be displayed to supply information to residents. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 17 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 are confident in the system of managing complaints and staff have a good level of understanding regarding the prevention of abuse. EVIDENCE: Residents said that they thought that if there was a problem then they were confident that the Manager or other staff would sort it out. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the local Social Service Department. The Registered Manager said this would be altered to reflect this issue. Staff members spoken with were aware of the full procedure regarding which outside Agencies to contact if the in house arrangement regarding protecting residents from abuse failed. The homes records were inspected and there were a number of complaints recorded in the file for the past year, which were recorded in detail and properly dealt with by management. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Facilities are seen as homely, clean and well maintained by residents. Odour control is of a very good standard. 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. Some residents said the home could be chilly on occasion. This was found to be the case by the inspector due to a change in the weather and with windows being left open, causing a draft. The Registered Manager said this issue would Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 19 be followed up by staff being reminded to check with residents as to whether they were warm enough. 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. The Registered Manager said that there were plans to redecorate and replace furniture in 2007, as money had been obtained from a grant. The light coloured carpet in the first floor corridor was clean, though stained, and will have to be replaced in the medium term. It is recommended that the Registered Manager investigate a signing system for residents with dementia, e.g. colour coding wc/bathroom doors, to complement the current system of having pictures on bedroom doors. There is already a board showing the date, weather etc, which provides information for residents with dementia. Radiator guards have been fitted to radiators to minimise any risk of burning to at risk residents. Lifts need to be reviewed to ascertain they are fit for purpose as they have broken down in the past year, thereby causing inconvenience for residents. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels may not meet all residents needs. The recruitment processes are thorough to ensure the full protection of residents from unsuitable staff. A staff training system is generally in place to meet residents needs. EVIDENCE: There were a number of comments made regarding staffing numbers not being sufficient to ensure that staff are always able to respond quickly to residents needs. The rota confirmed that there appeared to be a good number of care staff on duty during the day though the Registered Manager was asked by the inspector to review staffing levels to ensure that they meet all residents needs. The Registered Manager confirmed that at night there were two awake staff in the wing for residents with dementia and three awake staff in the main body of the home. There were also a small number of comments regarding staff not responding quickly to call bells. The Registered Manager said this issue would be followed Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 21 up by checking the response time of staff answering bells on the computer print out and asking senior staff on the floor to monitor staff performance Three staff files were inspected and contained all statutory information Protection of Vulnerable Adults checks that had been received before staff members had commenced employment with other information - references, work histories, identification etc. were seen to be in place. This helps protect residents from unsuitable staff. Some comments were received from residents that they sometimes cannot understand staff due to their accents – The Registered Manager said this issue would be followed up. There were also comments that some agency staff were not always aware of how to carry out basic tasks. The Registered Manager said a system would be put in place to ensure that their level of skills were checked and that she had already ensured that some staff did not return due to their unsuitability. Staff files contained evidence of training and 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 etc. The inspector asked that training in dementia should be added to this list as a high number of residents have this condition. The Registered Manager said this issue would be put in place. Training on residents health conditions – stroke, parkinsons disease, diabetes, hearing and sight impairment etc is also to be arranged so for staff to have a better understanding of these conditions and so be able to assist residents. The Registered Manager stated that staff are encouraged to undertake National Vocational Qualification training and staff spoken to confirmed this. The information provided on the Pre Inspection Questionnaire, that the Registered Manager provided prior to the inspection, stated that there were 50 of staff with National Vocational Qualification level 2, which meets the National Minimum Standard. Discussion with the Registered Manager indicated that the induction programme used for new staff is the National Training Organisation (Skills for Care) Standards, as per the National Minimum Standard. There was also an induction checklist on staff files on essential basic care and health and safety practice. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are generally in place to protect the health and safety of service users, though need to be tightened to provide full protection. EVIDENCE: Residents and staff said that they thought the Registered Manager and the management team were approachable and thoughtful as to the running of the home. Staff said they felt valued in their work by the management of the home. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 23 The Registered Manager has a National Vocational Qualification level 4 and is a qualified nurse. There were a small number of Policies and Procedures missing which The Registered Manager said this issue would be put in place. The Registered Manager said that a Quality Assurance system was in place for 2005, and a revised edition was going out for 2007 to residents, relatives and other stakeholders, e.g. GPs, District Nurses etc. It was recommended the results are included in the Statement of Purpose, with a summary of findings and information as to action to be taken where needed. There was evidence on staff records that staff have regular one to one supervision and staff confirmed that this occurred. Staff Meetings have been held and were recorded. It was recommended by the inspector that these are held more regularly to gather views on how to improve practice and ensure staff work consistently. The Registered Manager said this issue would be put in place. There is a Health and Safety folder with Risk Assessments for safe working. The Registered Manager said that window restrictors were inbuilt into all windows so that residents could not fall out. Service user monies records were generally found to be properly kept, with running balances and receipts but no recorded signatures, so that all transactions are witnessed. The Registered Manager said this would be carried out. Fire Precautions: System testing was on required schedules for fire bell testing and emergency lighting. Whilst there has been regular fire training, a recorded fire drill had not been carried out for nine months – the Registered Manager said this would be quickly carried and three monthly drills put in place. There was a basic fire risk assessment on file. The Registered Manager said that a detailed assessment would be put in place within two months of the inspection visit. Staff members were asked about the fire procedure and were fully aware of the whole procedure. The inspector observed one fire door wedged open to a small lounge. The Registered Manager said this was probably due to a visitor as it was not staff practice to do this. There needs to be a more attention to protect residents from hot water temperatures as the water tested was 47c in a bathroom and 61c in a visitors toilet that residents have access to. The National Minimum Standard is close to 43c. Evidence was seen of regular testing of hot water temperatures but this did not produce the desired protection from scalding temperatures. Charts Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 24 need to show what action was taken if water tested was too hot. The Registered Manager asked the maintenance person to turn down temperatures to a safe level. Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 25 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 26 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 always needs to be arranged to medical services if residents have significant injury, e.g. head injury, to ensure proper treatment is sought. Staffing levels need to be reviewed to ensure that they are always able to meet residents needs. Timescale for action 08/05/07 2. OP27 18 08/06/07 3. OP38 23 The Registered Provider must 08/05/07 ensure that all health and safety systems are in place to protect residents – e.g. that fire drills are regularly carried out, and that residents are protected from hot water temperatures. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000001898.V327447.R01.S.doc Version 5.2 Page 27 Devonshire Court 1. Standard OP7 It is recommended that care plans be reviewed to ensure they contain all aspects of residents needs and all relevant information is acted upon to meet residents needs. It is recommended that the food supply be reviewed to ensure there is a wide choice, that food always has good flavour and that all residents needs are catered for. 2. OP15 Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Devonshire Court DS0000001898.V327447.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!