Inspection on 04/12/06 for Devonshire Manor

This inspection was carried out on 4th December 2006.

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 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 04/05/06

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 Beate Roth Key Unannounced Inspection 10:00 4 and 6th December 2006 th 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.V313454.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.V313454.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 pgorry@aol.com 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.V313454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 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. At the time of this inspection the double room was used for single occupancy only and the registered manager confirmed that this room would only be shared should a positive desire to share a bedroom be expressed. 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. At the time of this inspection, the weekly fee for the home was £334.86. Additional charges are made for hairdressing, chiropody, toiletries, television license if under 75 years of age and holidays. A service user guide and the statement of purpose are available on request from the manager. A copy of the most recent inspection report can also be obtained from the manager. Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 9.5 hours and is based on two visits to the home. The inspection is also informed by information received about the service since the last inspection and by questionnaires completed by the residents and their relatives. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager and deputy manager. A tour of the home was undertaken and the opportunity was taken to speak with residents, relatives and staff. What the service does well: What has improved since the last inspection? The statement of purpose and service user guide now covers all the required information. There has been an improvement to the care planning information available for staff to refer to. The care plans now provide more detailed information on how Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 6 staff are to meet the needs of residents. Steps have been taken to record social history information for some residents, this provides staff with an insight into the residents life before they came to live at the home. An activities co-ordinator has been employed to work at the home for 15 hours per week. This ensures there are regular activities for residents to take part in should they choose to do so. The lounge and dining area have been redecorated and new carpet has been fitted in the lounge. This enhances this area for residents. There has been an improvement to the arrangements for storage at the home. There has been an improvement to the records around staff recruitment. These include the required information, which ensures that residents are safeguarded by the home’s recruitment practices. There has been some improvement to the systems in place for reviewing and improving the quality of care provided at the home. Since the last inspection, steps have been taken to formalise these systems. What they could do better: There have been a number of improvements in the operation of the home since the last inspection. However, the inconsistent approach in some areas means that some requirements have only been partially met. A concerted effort is now needed to ensure that the good work achieved is built upon. The following areas need improvement: All residents need to be provided with up to date written information around the fees payable at the home and what this covers. In order to demonstrate that all residents are given enough information about the home to help them decide if they should move in, it is recommended that a record be made of the date the service user guide is provided to residents. Improvements are needed to the medication records. The medication records must at all times reflect the medication that is prescribed for residents. When changes are made to the medication initially prescribed by a GP, if it is not possible for a GP to put changes made to medication in writing, then in order to safeguard residents two signatures need to be entered on to the MAR sheet following both staff having consulted with the GP. The initial assessment undertaken before residents come to live at the home and the service user plan need to indicate the support residents need to use the stair lift. Improvements are needed to the menu records to show that a choice of meals is offered and to enable residents to have access to a written menu. Residents Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 7 would benefit from having access to a complaint procedure, which details the process for residents making a complaint rather than how staff are to manage complaints. Although, residents benefit from staff being encouraged to undertake an NVQ 2 in Care of Older People, they would benefit further from new staff completing a formal induction and foundation-training programme. A number of staff have undertaken training in first aid, load management and food hygiene, since the last inspection, however, residents would benefit further if all staff that require this training had completed it. The management of records could be improved by filing them for ease of access and removing any records that are not in use. A consistent approach is needed to the quality assurance systems in order for them to be effective. The manager must demonstrate that she is keeping her skills and knowledge up to date. Improvements are needed around the records relating to fire safety. 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.V313454.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 Manor DS0000018882.V313454.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): 1, 2, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are assessed before moving to the home however these could be improved upon further by including more detail so that the home can be sure they are able to meet the specific needs of each resident. Resident’s benefit from being able to make trial visits. All residents must have up to date written information around the fees payable and what the fees cover. EVIDENCE: A statement of purpose and a service user guide are available. These documents have been revised since the last inspection and now cover all the required information. A new resident spoken with had been given a service user guide before moving to the home. Two residents spoken with who had been at the home for over 3 years also had a service user guide. The questionnaires returned by residents indicated that 7 out of 11 residents had received enough information about the home before they moved in. 3 residents had not received sufficient information, 1 resident could not recall the Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 10 information given to them. The manager reported that all residents have a copy of the service user guide. It is recommended that the date when this information is given to the resident be recorded. It continues to be recommended that the handwritten information in the statement of purpose and the service user guide be typed to give a more professional appearance. The manager or deputy manager visits all prospective residents to carry out an assessment before they are offered a place at the home. Two new residents had moved to the home since the last inspection. 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 residents and although fairly simplistic in style and content could provide the basic information from which a care plan could be developed. The initial assessments cover the religious, cultural and linguistic needs of residents. One new resident was spoken with and had been asked about their needs during the assessment. Written assessments by social workers where available as appropriate. It is recommended that further information be gathered for all residents around their social history. This had been gathered for some residents and provided details of their family and work history and significant life events. A new resident spoken with and staff confirmed that prospective residents 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. Contracts were available for the new residents and were in the process of being signed by the resident and/or their representative. The contracts covered the required information. The records for two residents who have been living at the home for over three years were seen. There was no evidence that these residents had been given up to date written information on the fees payable at the home. One of these residents was spoken with and confirmed this. At the time of the inspection it was observed that up to date contracts had been drawn up for each resident but had not been issued to residents and their representatives. Devonshire Manor DS0000018882.V313454.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 and 10 Quality in this outcome area is adequate. This is judgement has been made using available evidence including a visit to this service. The home has improved its approach to care planning with staff now having a clearer understanding of residents needs and how to meet them. The health care needs of residents are well met and residents are treated with respect. The management of medication in general supports the well being of residents although improvements are needed to the records of medication in order to fully safeguard residents. EVIDENCE: 5 care plans were seen. Since the last inspection the care plans have been revised and there has been an improvement to the care planning information that is recorded for the residents. The care plans identify the current needs of the residents and provide sufficient information for staff around the action to be taken to meet these needs. The staff spoken to, were aware of the needs of the residents whose records were inspected, and how to meet these needs. Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 12 The residents spoken to say that they are well cared for at the home. When asked about the care they receive from staff, residents said “the care is very good” and “we are well cared for.” 10 of the 11 questionnaires returned by residents indicated that they always receive the care and support they need from staff. 1 questionnaire indicated that the resident usually gets the care and support they need from staff. 2 relatives spoken with said that a good standard of care is given at the home and that they are happy with the service provided. 4 questionnaires returned by relatives indicated that they are happy with the overall care provided. Staff were observed to treat residents with respect. Staff were observed to speak to residents in a respectful manner and were sensitive when responding to the residents needs. The residents interviewed said that the staff are “polite,” “friendly,” “helpful” and “kind.” Staff receive guidance on promoting the dignity of service users. The questionnaires returned by residents indicated that staff are generally available when needed and that staff listen and act on what the resident says. The records at the home and a discussion with the manager indicated that referrals are made to health professionals in accordance with the needs of the residents. A record is made of visits by health professionals and the outcome is well documented. Residents spoken to say that their health needs are met at the home. The questionnaires indicated that the residents receive the medical support they need. The records of accidents are held on individual residents’ files. A sample were seen and were satisfactorily completed. An audit of accidents is now being completed as recommended at a previous inspection. A sample of the medicine administration record (MAR) sheets and corresponding medications were inspected. Two items of medication that were held for 2 residents were not indicated on the MAR sheet. The records of medication must clearly reflect all medication that is prescribed for a resident. A member of staff had made changes to the administration instructions for 2 types of medication following consultation with the GP. Any changes to a prescription need to be put in writing by the GP. If this is not possible then in order to safeguard resident’s two signatures need to be entered on to the MAR sheet following both staff having consulted with the GP. The amount of medication received or carried over is recorded on the MAR sheet so that an audit of medication is available. The supplying pharmacist has trained staff who administer medication in the administration of medication. Some of these staff have also completed training around giving medication as part of an NVQ in care of the elderly. At the last inspection a requirement was made that a formal means of assessing whether a worker is competent to give medication is put in place and a record be made in the member of staff’s training file. The manager and deputy manager reported Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 13 that when a new member of staff has been trained to administer medication their skills to administer medication would be assessed within supervision and recorded in the supervision notes. No staff have received training in the administration of medication since the last inspection. This matter will be looked at further at the next inspection. Following the last inspection consultation has taken place with Skills for Care, (the organisation that is working to ensure that care staff are appropriately trained), to ensure that the training provided to staff in the management of medication by the supplying pharmacist meets the Skills for Care standards. Steps are being taken to access a further training course for staff. During the homes own inspection of its medication procedures it was identified that a photograph of residents is not attached to the MAR sheet. It is recommended that this be addressed as this would help to guard against a possible error in medication administration. Guidelines around the safe storage of oxygen and around the support a resident needs in using oxygen is now available for staff. Devonshire Manor DS0000018882.V313454.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The wellbeing of residents is promoted by the flexibility of the daily routines. Visitors are made welcome to the home and the residents receive nutritionally well-balanced, appealing meals. Improvements are needed to the menu records to show that a choice of meals is offered and to enable residents to have access to a written menu. EVIDENCE: Since the last inspection an activities co-ordinator has been employed to work at the home 15 hours a week. A record of the activities available was seen. Armchair aerobics, films, a quiz, and bingo were activities recorded as being available for residents to take part in. Observations were made of a game of bingo and a quiz. The residents who took part said that they had enjoyed themselves. 10 of the 11 questionnaires returned indicated that residents are happy with the activities provided. One resident would like more opportunities to go out. Consideration should be given to how this can be organised. Some residents spoken with were happy to spend time alone reading or watching television rather than take part in an organised activity. Observations and a discussion with residents indicated that the routines of daily living are flexible. Residents said that the home encourages them to Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 15 make decisions about their day-to-day lives at the home, such as when they will get up and go to bed and what they will do each day. The resident’s bedrooms that were seen had been personalised with items brought in from their own homes. Information about advocacy services is available. Residents said they are consulted with about what activities and food they would like provided. The religious needs of residents are met. Some residents attend local churches and lay visitors from other religions visit the home. Visitors are welcome at the home at reasonable times. Residents can see visitors in private in their bedrooms. A quiet area is available in the dining room. The residents who were spoken with said they felt their visitors are made to feel welcome. Visitors were observed visiting the home during the inspection and were greeted warmly by the staff. 10 of the 11 questionnaires returned indicated that residents always like the meals at the home. 1 questionnaire indicated that the resident usually likes the meals. Residents spoken with said that the food provided was of a good quality and that they are happy with the variety. They also confirmed that they could choose between two meals at lunchtime and between several light meals at dinnertime. The record of meals shows that there is a good selection of well balanced meals provided. Special dietary needs are be catered for. At present a written menu is not available. The manager reported that meals are planned on a weekly basis in accordance with residents requests. Each day every resident is asked what they would like to choose from the choices available. A record of the daily choice of food available should be made as well as giving this information verbally to each resident. This can be documented in the food provided record book. However it is strongly recommended that a written menu be provided so that residents have access to both a written and verbal menu. Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 16 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 visiting the service. Residents know how to make a complaint and staff know how to manage complaints and adult protection matters. This means that residents are adequately safeguarded. Residents would benefit from having access to a more user friendly written complaint procedure. EVIDENCE: There is a complaint procedure available in the lounge. A complaints and comments book is also situated in the lounge. Although the complaint procedure provides information to residents around how to complain, the procedure is written for staff and indicates how staff are to manage a complaint. The residents spoken with said that if they had a complaint to make they would approach the manager or a member of staff. 9 of the 11 questionnaires returned by residents indicated that they know who to speak to if they are not happy. 2 questionnaires returned indicated that residents usually know who to speak to if they are not happy. One complaint is recorded in the record of complaints. This complaint was made to CSCI and was satisfactorily investigated by the home. The complaint was about the quantity and quality of food provided. A recommendation Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 17 around making a written record of the choice of meals available was made as a result of this complaint. Staff spoken to knew how to manage a complaint. A copy of Wirral Metropolitan Borough Council’s adult protection procedures is available at the home. The home also has a satisfactory adult protection procedure. 3 staff were interviewed and were very well aware of the procedure to follow should they suspect abuse. Devonshire Manor DS0000018882.V313454.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and satisfactorily maintained. The safety of residents is in general, promoted. 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. Since the last inspection, the carpet in the lounge has been replaced and the lounge and dining area have been redecorated. The walls to the hall on the first floor have been re-painted and the carpet has been replaced in this area. The decoration in bedroom 3 would benefit from attention, as there is a worn patch and a rip in the wallpaper. The registered person carries out remedial repairs and redecoration at the home as needed but as recommended at previous inspections a projected Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 19 programme of routine maintenance and renewal of the fabric and decoration of the home would assist the overall management processes. This would also contribute to ensuring the quality of the service provided. 10 of the 11 questionnaires returned by residents indicated that the home is always clean. Residents spoken with confirmed this also. At the time of this inspection appropriate storage arrangements were observed. A shed has been made available since the last inspection and is used to assist with the home’s storage. 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. Radiators have radiator covers in accordance with a risk assessment. The manager confirmed that any furniture at the home is fire resistant. In order to safeguard residents the initial assessment undertaken before residents come to live at the home and the service user plan need to indicate the support residents need to use the stair lift. The manager and deputy reported that being able to use the stair lift is considered during the initial assessment but that the help needed is not recorded. During a tour of the home some fire doors were seen to be wedged open. Fire doors must not be wedged open as they would be ineffective in the event of a fire. Fire doors may only be held open if an appropriate device that is approved by the fire service, is made available. Devonshire Manor DS0000018882.V313454.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. The records of the homes recruitment practices have improved and now evidence the necessary information needed to safeguarded residents. There are currently sufficient staff available meets the needs of the residents although, there is a need to ensure new staff complete a formal induction and foundation-training programme. Residents would benefit further form all staff having up-to-date training in first aid, load management and food hygiene. EVIDENCE: The rota for the week of the inspection indicated that there are a minimum of two care staff on duty at all times. Three staff are available in the morning until lunchtime. In addition there is a cook and domestic staff. Staff interviewed said that there are always sufficient staff available to meet the needs of residents. Residents interviewed said that there are always staff available to assist them. The questionnaires returned by residents indicated that staff are generally available when needed. At a previous inspection a requirement was made that a record of whether the rota was actually worked be maintained. This requirement continues to be met. A number of staff have worked at the home for several years and know the needs of the residents well. This promotes continuity of care. The friendliness Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 21 of the staff to each other and to residents was commented on by residents at this and previous inspections and was observed on the day of the inspection. One resident said “the atmosphere is lovely.” This creates a pleasant and relaxed atmosphere within the home. The manager reported that 5 out of 10 staff, have completed an NVQ 2 qualification in care of the elderly or equivalent. The records of training supported this. In addition, 4 further staff have nearly completed this qualification. At the last inspection, it was reported that the records of recruitment were not satisfactory as they did not contain all the required information. At this inspection, the records relating to four new members of staff were seen. These records contained all the required information. The manager reported that all staff receive a brief induction. This covers the home’s policies and procedures, day-to-day routines; resident’s care plans and health and safety issues. Following this the manager reported that further training is provided around meeting the needs of residents and health and safety matters. The manager reported that all staff are then encouraged to complete an NVQ in care of the elderly. At this inspection, a record was available of the induction training. At the last inspection, a recommendation was made that the induction and foundation training meet all of the targets recommended by Skills for Care. The home has introduced an induction and foundation training course, which meets these targets. This had been begun with the 2 new care staff (in addition to the above induction). However, not a great deal of the training had been competed. The deputy manager reported that staffing shortages have resulted in not being able to spend time completing this training with staff. Residents would benefit from staff completing this training. This must be attended to. At the last inspection it was reported that some staff had not received training in load management, first aid and food hygiene and that other staff were due for refresher training in these areas. A requirement was made that all staff must receive training appropriate to the work they perform. Since the last inspection, food hygiene training has been provided to 7 staff, first aid training has been provided to 4 staff and load management training has been provided to 6 staff. Dates have been set for further staff who have not got up to date training in these areas to complete courses early in 2007. The registered person is to confirm that this training has been completed. An audit of the training staff have undertaken has been completed since the last inspection. This will hopefully ensure that a plan to meet the further training needs of staff can be developed. Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 22 Certificates relating to the training recently completed by staff had not been received at the home. A copy of these certificates are to be forwarded to CSCI. Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 23 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for quality assurance and supervision of staff need further improvement. A consistent approach is needed to the quality assurance systems and arrangements for supervision in order for them to be effective. The safety of residents is in general promoted. Improvements are needed around the records relating to fire safety. EVIDENCE: The manager of the home has managed Devonshire Manor for 18 years. The manager reported that she has undertaken periodic training to maintain and update her knowledge, skills and competence. The records to support this Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 24 were not available. The registered manager has a Certificate in Social Services qualification. The manager reported that she is currently undertaking an NVQ Level IV in management. No further units have been completed since the last inspection. The manager must demonstrate that she is keeping her knowledge and skills up to date. There has been a general improvement to the management of records at the home, however there is room for further work here. Some information had not been filed and was not readily accessible. All filing should be completed and documents that are no longer in use should be stored elsewhere. There has been some improvement to the systems in place for reviewing and improving the quality of care provided at the home. Since the last inspection, steps have been taken to formalise these systems. A timetable has been drawn up that details the areas of the operation of the service that are to be assessed each month. This had been partially completed for November 2006 and the findings were very useful for improving the operation of the service and confirming what already works well. Staffing issues were reported as the reason for the quality assurance audit not being fully completed. A consistent approach is needed to the quality assurance systems in order for them to be effective. The results of questionnaires sent to residents and their relatives were available. Questionnaires had been sent to relatives and visiting professionals and the home is awaiting a response. Residents said that they are asked their views about decoration, food and activities to be provided. Staff said that their views about the running of the home are also obtained. The manager reported that the home does not look after any money for residents. The financial affairs of residents are managed by the residents themselves, or by their family or a solicitor. Residents are able to bring personal possessions to the home. A requirement has been made at previous inspections that all staff working at the home be appropriately supervised and a record be maintained of each supervision event. At this inspection, there has been an improvement in the arrangements for supervision of staff. The majority of staff have received formal supervision once since the last inspection and a records has been made of this. Staffing issues were again stated as the reason for why all staff have not received supervision. A consistent approach is needed to providing supervision in order for this to be effective. A sample of safety check records were seen for the electricity, gas, portable appliance testing, stair lift, bath hoist and contractors checks of the fire safety systems and nurse calls and were appropriately maintained. Records of inhouse checks of the fire alarm and emergency lighting were seen and were in order. A record of fire drills could not be located. The manager reported that a fire drill had taken place since the last inspection. Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 25 Staff interviewed had taken part in recent fire safety training and were aware of what action to take in the event of a fire. A discussion with the manager at the last inspection indicated that verbal guidance around the evacuation procedure is provided to staff, which is not fully recorded in the written evacuation procedure. A requirement was made that this be addressed. This has not been attended to. Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 26 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 2 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 27 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. Standard OP2 Regulation 17 Requirement The registered persons must ensure that all residents have up to date information on the fees payable at the home and what this covers. The registered persons must ensure that the records of medication clearly reflect all medication that is prescribed for a resident. The registered persons must ensure that any changes to a prescription are put in writing by the GP. If this is not possible then in order to safeguard resident’s two signatures need to be entered on to the MAR sheet following both staff having consulted with the GP. The registered persons must ensure that the initial assessment undertaken before residents come to live at the home and the service user plan indicate the support residents need to use the stair lift. DS0000018882.V313454.R01.S.doc Timescale for action 06/12/06 2. OP9 13 06/12/06 3. OP9 13 06/12/06 4. OP19 23 06/01/07 Devonshire Manor Version 5.2 Page 28 5. OP19 23 The registered persons must ensure that fire doors are not wedged open. Fire doors may only be held open if an appropriate device that is approved by the fire service, is made available. The registered persons must demonstrate that all staff have received training appropriate to the work they perform (previous timescale of 09/03/06 not met). A copy of the certificates of training for staff who have recently completed first aid, food hygiene and load management are to be forwarded to CSCI 06/12/06 6. OP30 18 06/01/07 7. OP30 18 The registered person must ensure that the induction and foundation training meets all of the National Training Organisation targets. The registered manager must demonstrate that they are keeping their knowledge and skills up to date. The registered person must maintain the system for reviewing and improving the quality of care provided at the home (previous timescale of 09/06/06 not met). The registered persons must ensure that all staff working at the home are appropriately supervised and a record maintained of each supervision event (previous timescale of 09/03/06 not met). The registered persons must DS0000018882.V313454.R01.S.doc 06/03/07 8. OP31 10 06/01/07 9. OP33 24 06/12/06 10. OP36 18 06/12/06 11 OP38 13 06/12/06 Version 5.2 Page 29 Devonshire Manor ensure that a record is maintained of fire drills. 12. OP38 13 The registered persons must ensure that the fire evacuation procedure covers the guidance provided to staff during the fire safety training (previous timescale of 10/06/06 not met). 06/01/07 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 OP1 OP1 Good Practice Recommendations It is recommended that the date the service user guide is given to the resident be recorded. The handwritten information in the statement of purpose and the service user guide should be typed to give a more professional appearance. It is recommended that further information be gathered for all residents around their social history. It is recommended that a photograph of residents be attached to the MAR sheet as this would help to guard against a possible error in medication administration. It is strongly recommended that a written menu be provided to demonstrate that there is a choice of meals available and so that residents have access to both a written and verbal menu. The complaint procedure should be amended so that it details the process for residents making a complaint rather than how staff are to manage complaints. 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 DS0000018882.V313454.R01.S.doc Version 5.2 Page 30 3. 4. OP3 OP9 5. OP15 6. OP16 7. OP19 Devonshire Manor repaired or replaced. 8. 9. 10. OP19 OP31 OP33 The decoration in bedroom 3 would benefit from attention, as there is a worn patch and a rip in the wallpaper. The registered manager is to complete an NVQ Level 4 in care. All filing should be completed and documents that are no longer in use should be stored elsewhere. Devonshire Manor DS0000018882.V313454.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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.V313454.R01.S.doc Version 5.2 Page 32 - 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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