Inspection on 08/10/07 for Devonshire House

This inspection was carried out on 8th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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

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

CARE HOMES FOR OLDER PEOPLE Devonshire House Devonshire House Care Home The Green West Auckland County Durham DL14 9HW Lead Inspector Mrs Sue Lowther Unannounced Inspection 8th October 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 House DS0000069688.V351862.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 House DS0000069688.V351862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Devonshire House Address Devonshire House Care Home The Green West Auckland County Durham DL14 9HW 01388 833 795 01388 832208 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) Devonshire House Care Ltd Mrs Marion Reed Care Home 25 Category(ies) of Learning disability (25), Physical disability (25) registration, with number of places Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 25 2. Physical Disability - Code PD, maximum number of places: 25 The maximum number of service users who can be accommodated is: 25 Date of last inspection Brief Description of the Service: Devonshire House is a converted large Edwardian House located in West Auckland. The home was originally opened in 1986 by a sole provider. However other members of the same family have recently become involved in the ownership of the home and have formed Devonshire House Care Ltd. There are 21 single and 2 double rooms located on three floors. These are accessible by means of a ramp and a lift. The home provides accommodation for mainly older persons who require either twenty-four hour general nursing or residential care. There is a varied and active recreational programme for those who wish to participate. The fees charged are between £399:50p and £419: 50p. This does not include the free nursing care element. The cost of hairdressing is not included. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 8th October 2007. During the inspection time was spent talking to people using the service, staff, relatives and management. A number of records were looked at and the grounds and building itself were inspected. The home was also asked to complete a self-assessment, which provided the inspector with information prior to the site visit. Surveys were also received from people who live in the home, their relatives and staff. Information gathered throughout the inspection maybe included within the inspection report. The inspection focussed on key standard outcomes for people who live in the home. What the service does well: What has improved since the last inspection? What they could do better: All of the people who live in the home must be supplied with statement of terms and conditions so that they know the amount they are being charged to live in the home and who is responsible for paying them. This must also say Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 6 what is not included in the fees. The programme of refurbishment should continue so that a high standard of accommodation is provided throughout the home. The manager said that a company representative visits the home on a minimum of a monthly basis to carry out an audit of the home. However there were no written reports available to confirm this. A report must be produced and a copy kept in the home for inspection purposes. 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 House DS0000069688.V351862.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. The home does not provide intermediate care and therefore assessment of standard 6 is not required. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Admissions are well managed and people are provided with information about the home before moving in. Some people have not received a contract to tell them what is included in the fees. EVIDENCE: The home provides a statement of purpose and service user guide, setting out its aims and objectives, the range of facilities and services it offers to people. This enables people to make fully informed choices about whether the home can meet their indivdual needs. People are encouraged to visit the home unannounced and spend time there. They can have a meal and talk to people to help them make a decision as to whether they would like to live there. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 9 People are only admitted after a full assessment of need is carried out by an appropriately trained person. This is usually the registered manager. This is to make sure that the home can meet the care needs of the people who go to live there. The family of one person who had recently gone to live in the home confirmed that they had looked around the home and had been supplied with all of the information they needed to make a decision about whether or not their relative would like to live there. However some people have not received contact which states who is responsible for paying the fees and informs the person what services are covered by them. The manager said that it is sometimes several weeks before she knows who is responsible for the fees. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. People’s health care needs are well managed by the home. Systems to administer medication are safe and people living at the home say that they are treated well and that the standard of care is good. EVIDENCE: All of the people who live in the home have care plans so that staff know how to look after people on an individual basis. There was evidence within some of the plans to confirm that people had been consulted with regard to their care. One of the relatives said, “ My relative is happy and well looked after-she has settled very well”. One professional person who was visiting on the day said, “I have never had to raise any issues with this home. I have always found the care to be very good”. One of the people who lives in the home said, “This home provides a good service to meet all of my needs”. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 11 Records examined showed that people receive visits from other healthcare professionals. These include district nurses, doctors, and care managers. Medication is administered by qualified nurses and the home has a comprehensive medication policy. Accurate records of all medicines received, administered and those leaving the home are maintained. People spoken to said that staff always treat them with dignity and respect. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home provides a range of activities which are suitable for most of the people who live in the home. Relatives are made welcome and encouraged to visit the home. People living at the home said that they were able to make choices within all aspects of daily living. There is a varied menu and people likes and dislikes are well catered for. EVIDENCE: The activities are arranged by two carers. Comments about these were mixed, although the majority were good. One person said, “I enjoy any parties or entertainment”. Another said, “I would like more social evenings like a quiz night or coffee morning and more social outings”. The manager said that most people wanted more outside entertainers especially singers. This issue was being addressed as far as possible. People can have visitors at any time and private visiting areas are available. People’s spiritual needs are respected. One person said, “ My relative is a Catholic and she was immediately put in touch with a lady from the church who visits on a regular basis”. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 13 People are encouraged to make choices and decisions wherever possible and this was observed throughout the day. One person said “I can get up and go to bed when I want. I go to bed at 11:30 and get up really early”. Meals are varied, appealing, nutritious and based on individuals choice. The choice of menu is recorded daily but remains flexible. Special dietary needs are catered for and people are assisted to eat if necessary. One person who lives in the home said “The food is good. We get a choice and there is definitely plenty”. One relative said, “The meals are always appetising and well thought out.They try their best to provide different meals each day for people who have very limited tastes and preferences”. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Complaints are well managed and are supported by clear guidance and training. Staff are trained in adult protection and know the procedure to follow. The written policy requires review so that it complies with locally agreed procedures. EVIDENCE: The home has a complaints procedure in place, which is displayed throughout the home. People who live in the home said that they would know how to make a complaint. One person said, “I would ask to see the manager. ”. One visitor said “If I have a problem I just tell the manager and things are done promptly. I rarely have any problems”. Staff said that if they have a problem they feel that they can approach the manager and she tries her best to sort it out. Staff are trained to recognise and prevent abuse of the people who live in the home. The home has an adult protection procedure. During the inspection the manager said that this was being reviewed to comply with the locally agreed procedure. The home also has an active whistleblowing policy. All staff spoken with said that they would have no hesitation in whistle blowing (telling someone) if there was a problem. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home is clean, well maintained and furnished and decorated to a good standard. EVIDENCE: Parts of the home have been refurbished to provide a good environment for the people who live there. Many of the bedrooms have been personalised to individual choice and taste. There are a variety of lounge/dining areas for people to enjoy. There are bathrooms throughout the home which have adaptations to assist those who are less mobile. The building complies with local fire and environmental health regulations. The premises were clean, hygenic and free from any odours. Policies for the control of infection are in place and adequate handwashing facilities are available. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Staffing numbers support people’s needs. The home has a commitment to staff training and recruitment practices protect people living in the home. EVIDENCE: The home had staff files in place, which provided evidence that the appointment of new members of staff is made through proper recruitment processes. This includes the vetting of staff through the use of Criminal Record Bureau (CRB) checks, Protection of Vulnerable Adult checks (POVA) and written references. The staffing rotas were examined during the inspection. Staff felt there were sufficient numbers on duty to meet the needs of the people who live in the home. One person who lives in the home said, “Very well staffed, one of the finest type of staff it is possible to get”. The home has an induction programme in place for all newly recruited staff. Recent training has also taken place in the Mental Capacity Act, moving and handling, health and safety, wound care and peg feeding. Certificates to confirm this were seen in staff files. A high proportion of care staff are trained to NVQ (National Vocational Qualification) in care at level two or above. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home is well managed and relatives and people using the service are regularly consulted about the service they receive. Financial arrangements are good and health and safety systems and practices protect people. EVIDENCE: The manager is well qualified, with several years experience in working with older people. She is a qualified nurse and holds an appropriate management qualification. There are clear lines of accountability within the home. Staff, relatives and those living at Devonshire House are actively involved in the decision making process of the home. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 18 The home has an annual plan for quality assurance which includes, meetings with people using the service, relatives and staff. These are held monthly and information from these are included in quality monitoring. The manager said that a company representative visits the home on a minimum of a monthly basis to carry out an audit of the home. However there were no written reports available to confirm this. A report must be produced and a copy kept in the home for inspection purposes. Personal finances are kept in the home for people who request this. Two signatures are obtained and receipts are kept to ensure peoples’ financial interests are safeguarded. Health and safety systems were looked at. Safe working practices are maintained in line with current regulations and appropriate risk assessments are available. All safety checks for maintenance are carried out by external contractors as designated by law. The CSCI received an anonymous comment that the fire in the lounge was not maintained and that some electrical sockets are dangerous. Evidence was seen to confirm that maintenenace of the fire is carried out on a regular basis. The manager said that a potential incident had been reported with regard to an electrical socket. An electrician was called promptly and confirmed that the socket was safe. All accidents are recorded and reported appropriately. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 19 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 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? N/A 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 OP2 Regulation 5 Requirement Timescale for action 31/12/07 2. OP33 24 & 26 All of the people who live in the home must be provided with a statement of terms and conditions, which clearly states the fees paid and who pays them. The registered person must 31/12/07 provide a written report to demonstrate that a monthly monitoring visit of the home has taken place. A copy of this report must be available within the home for inspection purposes. 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 OP26 Good Practice Recommendations The programme of refurbishment should continue so that a high standard of accommodation is provided throughout the home. Devonshire House DS0000069688.V351862.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 House DS0000069688.V351862.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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