Inspection on 20/09/05 for Devonshire Manor

This inspection was carried out on 20th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 11/03/08

Devonshire Manor 04/12/06

Devonshire Manor 04/05/06

Devonshire Manor 09/03/06

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 Beate Roth Unannounced Inspection 20th September 2005 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 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 F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Devonshire Manor Address 38-40 North Road Birkenhead Wirral CH42 7JF 0151 652 2274 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Patricia Mary Gorry Mrs Patricia Mary Gorry Care Home 15 Category(ies) of OP Old age registration, with number of places Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 12/01/2005 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. All service users are accommodated in single rooms unless they choose to share. The home has two floors. Bedrooms are situated on both the ground and first floor. A stair lift is available. Toilets are situated on both 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 are a small selection of shops within walking distance. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager. A tour of the home was undertaken. Staff were observed delivering care to service users. The inspector spoke to service users, their relatives and to staff. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose and the service user guide are to be updated so as to provide accurate information about the staff and services available at the home. Improvements need to be made to the adult protection procedure to ensure that service users are appropriately protected. The records relating to staffing available at the home, fire training for staff, fire drills and the assessment of risk presented by the few uncovered radiators need attention. Action needs to be taken to ensure that the arrangements for quality Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 6 assurance and supervision of staff better support the well being of service users. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5 Service users have their needs assessed before moving to the home and they benefit from being able to make trial visits. The written information given to service users about the services at the home needs updating. EVIDENCE: A statement of purpose and a service user guide are available that describe the services at the home for prospective service users. Service users are given a copy of the service user guide on admission to the home. Both documents contain information about staffing and services that are no longer relevant. The manager reported that these documents are due to be reviewed and that a revised copy will be forwarded to CSCI. The revised statement of purpose needs to include information about the sizes of communal space and bedrooms available. The manager visits all prospective service users to carry out an assessment before they are offered a place at the home. The assessment documents examined had been completed either with a tick box or a brief comment. They identified the main areas of need for each of the service users and although Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 9 fairly simplistic in style and content could provide the basic information from which a care plan can be developed. Inspection of records and discussion with the manager, service users and their relatives confirmed that prospective service users are able to visit the home on an introductory basis. During these visits they can meet staff and current service users and view the home. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 The health, personal and social care needs of service users are set out in the service user care plans. Service users are adequately protected by the home’s procedure for medication management. EVIDENCE: A sample of service user care plans were viewed. These provide brief but satisfactory information around the health, personal and social care needs of service users and how staff are to meet them. The service users spoken to said that they are well cared for at the home. When asked about the care they receive from staff, service users said “the staff are spot on” and “staff are very good.” This was also confirmed by relatives spoken with. The records showed that consultation takes place with social and health care professionals when needed. A sample of the medicine administration record sheets and corresponding medications were inspected and found to be correctly maintained. Staff have been trained in the administration of medication by the supplying pharmacist. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The daily routines at the home and activities on offer ensure that the preferences of service users are provided for. EVIDENCE: Discussion with service users and relatives indicated that the home’s routine was flexible and met service users expectations, as much as possible. The views of service users are sought about the activities to be provided. Staff were observed to speak to service users in a respectful manner and knocked at bedroom doors before entering. The records of menus were inspected and showed that a varied diet was being provided at the home. Service users confirmed that the food provided was of a good quality and that they are happy with the menu. They also confirmed that they could choose an alternative meal to the one provided. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Service users know how to make a complaint. Improvements need to be made to the homes adult protection procedures to ensure service users are protected from abuse. EVIDENCE: There is a complaint procedure available that provides clear guidance. Information about how to complain is also contained in the service users guide. The service users spoken with knew how to make a complaint. No complaints have been made to the service since the last inspection and CSCI has not received any complaints about the service. An adult protection and a whistle blowing policy and procedure are available. The adult protection procedure has been reviewed since the last inspection. This refers to staff investigating an allegation of abuse. This would not be the appropriate course of action to take. Allegations of abuse are to be referred to social services. The adult protection procedure is to be amended accordingly and steps are to be taken to ensure that all staff are appropriately trained in the protection of adults from abuse. Several members of staff have completed adult protection training as part of the NVQ 2 and when interviewed at previous inspections were fully aware of the correct adult protection procedure to follow. Advice was given around how to obtain a copy of Wirral Borough Council’s adult protection procedures. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home is clean and satisfactorily maintained, providing service users with a pleasant environment to live in. EVIDENCE: The premises are in keeping with the local community. The home is close to local amenities local transport and relevant support services. A tour of the home was undertaken and a sample of bedrooms seen. The home was clean and satisfactorily maintained at the time of the inspection. Bedrooms are personalised. The registered person continues to carry out remedial repairs and redecoration at the home but as recommended in the previous inspection report a projected programme of routine maintenance and renewal of the fabric and decoration of the home would assist the overall management processes. This would be another way of ensuring the quality of the service provided. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 14 Steps have been taken to ensure that a safe environment is provided. Water is regulated throughout the home to ensure that the temperature does not exceed 43 degrees centigrade. Regular checks of the water temperature are undertaken. A number of the radiators have radiator covers in accordance with a risk assessment. Radiator covers are not fitted in 2 bedrooms and in the bathrooms. The manager reported that this is in accordance with a risk assessment, this risk assessment was not documented. This is to be addressed. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 The rota indicates that the staffing arrangements at the home do not fully protect service users. Service users benefit from having 50 of staff with a professional qualification. EVIDENCE: At the time of the inspection 10 service users were living at the home. The rota for the week of the inspection indicated that in general there are a sufficient number of staffing hours during the day and through the night to meet the needs of the service users. The rota showed that there were periods when only one member of staff is on duty, which would not be acceptable. The manager reported that she has not included the additional hours covered by staff whilst a member of staff is on annual leave. This was confirmed by a member of staff spoken with, who said that as a minimum there are always two staff available. The service users and relatives spoken with reported no staffing problems. The rota must be an accurate reflection of staffing arrangements at the home. This issue was addressed with the manager following the inspection. A record of whether the rota was actually worked also needs to be maintained. 50 of staff have completed an NVQ 2 qualification in care of the elderly. Further staff are currently undertaking this training. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 16 No new staff have been employed since the last inspection. The information that was not available for new staff employed at the last inspection, has now been obtained. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36 and 38 The arrangements for quality assurance and supervision of staff do not support the well being of service users. EVIDENCE: There are systems in place for reviewing and improving the quality of care provided at the home. There continues to be no formal quality assurance system in place that would confirm the success of the home in achieving its stated objectives. The registered person is in the process of re-issuing a questionnaire to service users and their relatives and this would enable the home to meet the relevant requirements if the results could be formed into a coordinated response, with an action plan for future development. Additionally a questionnaire for GP’s, district nurses and other visiting professionals would complete the quality assurance process. A requirement was made at the last inspection that all staff working at the home are appropriately supervised and a record maintained of each Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 18 supervision event. At this inspection, informal supervision is continuing. No records are maintained and the process would not support any actions taken with members of staff to support references or disciplinary action. Paperwork is available to meet this requirement. Appraisals of staff are currently being undertaken. A sample of safety check records were seen and in general were appropriately maintained. A record had not been made of fire drills and fire safety training provided to staff. This is to be addressed. The manager and staff reported that they have received health and safety training. Only a few training certificates were available to confirm this. A copy of these certificates should be held at the home. Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 1 x x 1 x 2 Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 1 18 Regulation 6 13 Requirement The statement of purpose and the service user guide must be reviewed. The adult protection procedure must be amended to reflect that allegations of abuse are to be reported to social services. All staff must receive appropriate training around adult protection. The risk assessment for the unguarded radiators is to be recorded. Steps must be taken to address any risks presented. The rota must accurately reflect the staffing arrangements at the home. A record of whether the rota was actually worked must also be maintained. The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the home (previous timescale not met). The registered person must ensure that all staff working at the home are appropriately supervised and a record maintained of each supervision event (previous timescale not met). F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Timescale for action 20/12/05 20/10/05 3. 19 13 27/10/05 4. 27 17 20/09/05 5. 33 24 20/12/05 6. 36 18 20/09/05 Devonshire Manor Version 1.30 Page 21 7. 38 13 A record must be made of fire drills and fire safety training provided to staff. 20/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 18 19 Good Practice Recommendations A copy of Wirral Borough Councils adult protection procedures are to be obtained. 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. A copy of all training certificates awarded to staff are to be held at the home. 3. 38 Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 22 Commission for Social Care Inspection Liverpool Area Office 3rd Floor 10 Duke Street Liverpool, L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Devonshire Manor F52 F02 S18882 Devonshire Manor V252664 200905 Stage 04.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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