Inspection on 11/03/08 for Devonshire Manor

This inspection was carried out on 11th March 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Devonshire Manor 18/11/09

Devonshire Manor 10/03/09

Devonshire Manor 04/12/06

Devonshire Manor 04/05/06

Devonshire Manor 09/03/06

Devonshire Manor 20/09/05

Devonshire Manor 12/01/05

Devonshire Manor 29/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Devonshire Manor 38 - 40 North Road Birkenhead Wirral CH42 7JF Lead Inspector Natalie Charnley Key Unannounced Inspection 11th March 2008 10:00 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 Manor DS0000018882.V361492.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 Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Devonshire Manor Address 38 - 40 North Road Birkenhead Wirral CH42 7JF 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) 0151 652 2274 0151 653 6731 No email Mrs Patricia Mary Gorry Mr Thomas Charles Gorry Mrs Patricia Mary Gorry Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th December 2006 Brief Description of the Service: Devonshire Manor is registered to provide personal care to 15 older people. There are 13 single and one double bedroom. The home has two floors and a mezzanine floor. Bedrooms are situated on all floors. A stair lift is available. Toilets are situated on the ground, first and mezzanine floors. There is a bathroom on the ground and on the first floor and bathing aids are provided. Communal space is provided in a lounge with through dining room. There is car parking space at the front of the building and a ramp for wheelchair access. A paved outdoor area is provided with flowerbeds and shrubs. The garden is accessible by wheelchair. The home is situated in the Tranmere area of Birkenhead and is convenient for local bus routes across the Wirral. There is a small selection of shops within walking distance. It costs £352 per week to live at the home. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 5 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 site visit to the service was unannounced and was carried out over a period of one day. We spoke with 4 staff, the registered manager/owner and 6 residents about what it was like living and working at the home. We also spoke to 2 visitors. The manager was asked to provide a selection of information in the form of an annual quality assurance document (AQAA), is to be used as part of the inspection process. Comment cards were sent to the home for people who live at the home and staff to complete. This gave them the opportunity to contribute to the inspection process. The AQAA was not returned by the service, despite being given a 2 week extension. We completed the inspection by looking at the homes records, a tour of the building, formal and informal interviews and information from previous inspection reports. Feedback was given to the person in charge during and at the end of the inspection. What the service does well: People like the staff that care for them, commenting that they are “ very good at their jobs”. People are given the opportunity to make decisions about their everyday lives. This helps them to maintain control over what they do. The staff team at the home work well together and staff turnover is low. This provides a homely and stable place for people to live. People enjoy their meals and can have alternatives if they so choose. Comments were made such as “ the food is delicious”. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Devonshire Manor DS0000018882.V361492.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 Manor DS0000018882.V361492.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service cannot be sure that they can meet the needs of people who move in. This may result in people moving to the home that cannot be cared for in the correct way. EVIDENCE: There has only been one admission to the service since the last inspection. There was a very basic pre admission assessment available but this did not provide sufficient detail about what care that person needed when moving into a new home. There was limited information about their medical conditions and no information about their social interests or hobbies. Information must be recorded that will allow the manager to make an informed decision as to if the service can meet the needs of the individual. Discussion took place with the person who was last admitted to the service who explained that they had been made aware of exactly what to expect. They Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 9 commented, “ The manager gave me all the information I needed and I knew exactly what was going to happen and when”. Staff spoken with stated that when someone new moves in the manager talks to them about what care that person will need. One member of staff commented “ we are always told about what someone will need, but we are lucky here as we seem to have the same residents for a long time, and don’t often have new people. That makes it homely”. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Records need to be improved to ensure that people receive the appropriate care and support. EVIDENCE: We looked at three care files. Care plans were poor and did not contain details regarding what care individuals need. Staff could therefore not follow this information when providing care, which could leave people at risk. One plan stated that a person had hallucinations, but staff reported this had now stopped. The plan didn’t reflect these changes and had not been updated. This could mean the person was not receiving the correct support. Records were not always maintained for people’s weights and care plans were not being reviewed on a monthly basis. This also means that people may not be receiving the care they need. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 11 Staff spoken with were able to demonstrate a good knowledge of the needs of people using the service. They were aware of the individual needs and preferences of all the people living at the home. People using the service described their care as “ excellent”, “ couldn’t be better” and “tip top”. Records must be improved to ensure the care that people are receiving can be continued in the event of new staff starting, and that the care that is being given is appropriate. Records and discussions with people showed that people have access to health professionals such as GP’s (General Practitioners), Opticians and District Nurses. This helps ensure that people receive extra help if they need it. The service has a number of people who have diabetes. It is recommended that staff undertake nutritional screening of people to ensure that anyone who is at risk is identified. Medication records and storage areas were checked. Records were of a high standard and showed that people received the medication they needed. It is recommended that controlled drugs be kept in the controlled drugs cabinet rather than in the general medication storage cupboard, as this will ensure they are kept secure. Staff spoken with stated that they had received medication training and felt able to do this task safely. People were able to give examples of how staff treat them with respect and maintain their dignity. One person commented “ I can always see my visitors in private if I want to”. Staff were observed to be talking to people in a polite and caring way and knocking on bedroom doors before entering. Devonshire Manor DS0000018882.V361492.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to make individual choices in their everyday lives. This helps them maintain their independence. EVIDENCE: There is no formal plan of activities at the home, they are offered on an ad hoc basis. Staff stated that people who use the service were not keen to join in and preferred to watch television or DVD’s. People spoken to agree this was the case. One person commented, “ we like to to sit and chat and watch the tele, we are not like children and can decide for ourselves what we want to do”. Records showed that recently people had participated in bingo, reminiscence, and had an outside entertainer in. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 13 Three people are supported to attend local churches and religious leaders visit the service on a regular basis. Visitors communed that they were made welcome at all times and felt “just as loved” as the people who live there. People spoken with gave examples of the choices that they make on a daily basis. People can chose what time to get up and go to bed, what meals they want and what they wear. One person commented, “we can pretty much do as we please here, we aren’t stopped from doing anything we want to”. Bedrooms sampled showed that people had been encouraged to personalise them with photographs and items of furniture. This helped created a homely atmosphere. People were observed having lunch. This was noted to be a social and unhurried occasion. Staff were on hand to assist people who needed help and everyone appeared to enjoy their meal. People commented, “ the food is lovely here, you can’t fault it” and “ it’s really tasty”. The cook explained how she managed diabetic diets to make sure peoples health was maintained. Discussion with people and the cook showed that whilst there is a set meal offered daily, if people don’t like it or want something different this is accommodated. One person was able to give a recent example of when she had received an alternative meal. Devonshire Manor DS0000018882.V361492.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints policies must be made accessible for everyone. This is to ensure people are to voice their opinions. EVIDENCE: The service has not received any complaints since the last inspection. Four people spoken with, including a visitor stated they were aware of how to make a complaint and that they had seen the policy on display around the home. One person commented “ I would tell the manager if there was anything wrong, but I know there are outside people who can also help if I need them”. Two people stated that they had not seen the complaints policy and were not aware of the details in it. The manager must ensure everyone who uses the service is made aware of what to do if they have a complaint, in case they need to use it. All staff have received training on safeguarding adults and were knowledgeable about what to do in the event of an allegation of abuse. The copy of the local authority policy on safeguarding couldn’t be located during the visit. This is the tool used in the event of an allegation of abuse. It must be available for staff to access if they need it. Internal company policies were available which Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 15 covered protection, equal opportunities and whistle blowing. These help protect the welfare of both staff and people using the service. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service is well maintained, homely and suitable for the needs of people who live there. EVIDENCE: A tour of the home showed that it was homely, warm and well lit. New carpets had been purchased for the majority of bedrooms, along with new beds. This has help create a pleasant atmosphere for people to live. People commented, “I love living here, my room is nice and I am well cared for” and “ I like sitting in this nice lounge, its always clean and tidy”. Bedrooms were personalised with items from peoples homes and lockable storage is available for the safekeeping of belongings. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 17 Domestic staff are employed to keep the home clean and tidy and a small laundry is available. Policies and procedures are in place for infection control which helps protect the welfare of people using the service. Staff spoken with stated they had not received training on infection control but that they were aware of the service policy. Training in this area would help ensure the safety of people using the service. There is an allocated member of staff who deals with maintenance and repairs. Records are kept of these jobs to ensure they care completed. Due to the nature of the building, ongoing maintenance is required and a rolling plan of redecoration is in place, however at present this is informal and not recorded. It is recommended that a formal plan be drawn up to ensure the home is kept well maintained. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People like the staff that care for them, however lack of staff training may result in poor care practices. EVIDENCE: The staffing rota was sampled and showed that there was sufficient staff on duty to meet the needs of people living at the service. People stated staff were “warm and caring”, “ friendly” and “very, very nice”. People stated that there was always a member of staff around if they needed them and that the staff team didn’t often change, leading to a stable team that knew individuals well. Three staff files were sampled, including that of a brand new member of staff. Records showed that all staff had undergone Police checks to make sure they are suitable to work with vulnerable people. References had also been taken regarding their suitability for care work. Staff spoken with stated they enjoyed their work and felt they worked well as a team. One member of staff commented, “ It’s a happy home”. Staff detailed training that they had undertaken, however not all staff had received training in mandatory subjects such as manual handling and first aid. Training records were unclear and were not able to provide evidence that all training had been Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 19 completed. Some staff files contained training certificates, however the manager had no way of knowing which member of staff was up to date in which area. It was also unclear as to which staff had completed their NVQ (National Vocational Qualification) in care. The manager must audit the training records and make a plan for future training needs. This is to ensure staff are able to provide the correct care for people using the service. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People are not given the opportunity to participate in the running of the home and safety checks leave people at possible risk. EVIDENCE: The owner/manager of the service has owned and run the home for twenty one years. The manager reported that she has undertaken periodic training to maintain and update her knowledge, skills and competence. The records to support this were not available. The registered manager has a Certificate in Social Services qualification, but has not achieved her NVQ level 4, which is a specialist qualification in running a care home. This qualification must be Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 21 undertaken by people who manage a home to ensure they have the knowledge and skills to do so. The manager stated that she sends out questionnaires to relatives and visitors on a bi-monthly basis, however never receives any back. No evidence of these questionnaires was available to sample. There was no annual development plan available to show what areas of the service are to be reviewed. People who use the service stated that, whilst they were very happy with the care they received, they had never been asked how it could be improved. A residents meeting had been held recently, and very basic records were available, however the last meeting before this was in 2005. It is important to make sure people using the service are able to give their views and opinions. A system for gathering this information must be established at the service as a matter of urgency. Whilst a set of policies and procedures is available at the service, there was no evidence to show that these had been updated. It is recommended that this be done to ensure that policies are kept in line with current practice. The manager reported that she does not look after any money for people living at the service. The financial affair are managed by the people themselves, or by their family or a solicitor. Safety certificates were sampled. All were up to date with the exception of the portable appliance tests, which were a month out of date. Tests for these items must be arranged in order to protect people using the service. Fire test checks could not be located during the visit, however the manager reported they had been done. These tests must be completed and records maintained for inspection to ensure the safety of people using the service. Accident records had been completed correctly and stored in accordance with the Data Protection Act. This ensures that records are kept private and confidential. It is recommended that the manager audit accidents to check for any trends. This will help identify if people are at risk. Basic risk assessments were available in care plans, however these must be completed in full to ensure they are up to date and the correct care is provided. Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 17 x 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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. OP3 Standard Regulation 14 Requirement Detailed assessments must be completed before people move to the home. This will ensure that the service are able to meet the needs of individuals Care plans must be detailed and include enough information for staff to provide appropriate care. Plans must also be reviewed monthly. This will ensure they are up to date. People must be made aware of how to make a complaint. This is to ensure that people can voice their opinions. Staff must be provided with appropriate training to undertake their roles. Records of this training must be kept. This will ensure all staff receive the training they need. The registered manager must undertake training to ensure she is capable of running the service. A system must be established for monitoring the quality of care at the service. This will ensure improvements can be made. Safety checks must be DS0000018882.V361492.R01.S.doc Timescale for action 01/05/08 2. OP7 15(1) 01/05/08 3. OP16 22 01/05/08 4. OP30 18(1)(c) 01/07/08 5. 6. OP31 OP33 10(3) 24 01/07/08 01/05/08 7. OP38 23 01/04/08 Page 24 Devonshire Manor Version 5.2 completed on portable appliances and fire safety issues. This will ensure the safety of people using the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP8 OP9 OP18 OP19 Good Practice Recommendations Nutritional screening should be carried out on people who use the service. This will identify if any one is at potential risk. The formal controlled drug cabinet should be used. This will ensure medications are kept safe. A copy of the local safeguarding policy should be made available to staff. This will ensure they have access to information they need. The registered person should produce a planned maintenance programme for the home indicating the years in which the fabric and furnishings of the home will be repaired or replaced. Staff should be supported to undertake their NVQ qualifications in care. Records should be kept to prove that this has been done. This will ensure staff are trained to do their jobs. Audits of accident records should be carried out. This will highlight if any trends are occurring, allowing staff to address them. The service should audit staff training records to get a clear picture of which staff need which type of training. This will ensure people receive the training the need to carry out their jobs. 5. OP28 5 6 OP38 OP30 Devonshire Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Manor DS0000018882.V361492.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!