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Inspection on 04/05/06 for Devonshire Manor

Also see our care home review for Devonshire Manor for more information

This inspection was carried out on 4th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users have their needs appropriately assessed before moving to the home, which, ensures that a service is only offered to people whose needs can be met. Service users benefit from being able to make trial visits. This assists service users to make a decision about whether the home is right for them. Staff are aware of the needs of service users and how to meet them. Service users spoken with reported that a good standard of care is provided. Observations and discussions with service users indicated they consider they are treated with respect. The wellbeing of service users is promoted by the flexibility of the daily routines and by the opportunities for service users to make choices. There are enough staff available to look after the service users who live at the home. Service users benefit from staff being encouraged to complete a qualification in care, as this ensures staff have a greater understanding of how to care for older people. A number of staff have worked at the home for several years and know the needs of the service users well. The friendliness of the staff to each other and to service users was commented on by service users at this and previous inspections and was observed on the day of the inspection. This creates a pleasant and relaxed atmosphere within the home.

What has improved since the last inspection?

Work has taken place to meet the requirements and recommendations made at the last inspection. Where requirements remain outstanding, progress has generally been made towards meeting them. The service user guide has been improved, providing clearer information for service users. There have been improvements to the information available to staff around adult protection. Steps have been taken to meet the health and safety issues identified at the last inspection. An up to date fire drill has taken place, fire safety training has been provided to staff, a gas certificate is available, a bed rails risk assessment has been developed and radiator covers fitted to two radiators in accordance with a risk assessment. There have been improvements to the record keeping around the times staff work at the home. The staffing rota accurately reflects the staffing arrangements at the home and a record of whether the rota was actually worked is being maintained. Records, for recording complaints were available at this inspection. An audit of accidents is being maintained which will assist care and service planning.

What the care home could do better:

Although there has been an improvement to the records since the last inspection, there are areas, where further improvement is needed. The statement of purpose and service user guide must provide an accurate account of the service offered to service users and their representatives. The service user care plans must contain clear information as to the action staff are to take to meet the needs of the service users, so that the well being of service users is promoted at all times. A record must be made of the competence of staff to administer medication and a clear audit of the amount of medication available needs to be maintained to ensure the safety and well being of service users. In order to show that service users are being protected by the home`s recruitment procedure, the records that are required by law must be available for all care staff employed at the home. At the last inspection records were difficult to find. There has been a general improvement to the storage of records, however there is room for further work here, in particular, policies and procedures need to be more accessible for staff and any documentation not in use should be stored elsewhere. In order to meet the needs of service users, staff must receive training appropriate to the work they perform. This inspection identified that some staff had not received or not undertaken refresher training in first aid, load management or food hygiene. An audit of the training staff have undertaken should be completed to ensure that a plan to meet the training needs of staff can be developed. The plan for providing a more detailed staff induction and supervising staff to ensure they have the knowledge and competence to work at the home are in the early stages of being developed. This provides a good basis for supporting staff and it is anticipated that significant progress will have been made at the next inspection. Attention is needed to health and safety issues in order to safeguard service users. Guidelines around the safe storage and use of oxygen need to be made available. The fire evacuation procedure needs to cover the guidance provided to staff during the fire safety training. Evidence that a bath hoist is safe for use must be provided to CSCI.

CARE HOMES FOR OLDER PEOPLE Devonshire Manor 38 - 40 North Road Birkenhead Wirral CH42 7JF Lead Inspector Beate Roth Key Unannounced Inspection 09:00 4 and 10th May 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.V288740.R01.S.doc Version 5.1 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.V288740.R01.S.doc Version 5.1 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 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.V288740.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 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 room 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 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.V288740.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took 9 hours over a two-day period. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager and deputy manager. A tour of the home was undertaken. Staff were observed delivering care to service users. The inspector spoke to service users and to staff. What the service does well: What has improved since the last inspection? Work has taken place to meet the requirements and recommendations made at the last inspection. Where requirements remain outstanding, progress has generally been made towards meeting them. The service user guide has been improved, providing clearer information for service users. There have been improvements to the information available to staff around adult protection. Steps have been taken to meet the health and safety issues identified at the last inspection. An up to date fire drill has taken place, fire safety training has been provided to staff, a gas certificate is available, a bed rails risk assessment has been developed and radiator covers fitted to two radiators in accordance with a risk assessment. There have been improvements to the record keeping around the times staff work at the home. The staffing rota accurately reflects the staffing arrangements at the home and a record of whether the rota was Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 6 actually worked is being maintained. Records, for recording complaints were available at this inspection. An audit of accidents is being maintained which will assist care and service planning. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 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.V288740.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. Service users have their needs assessed before moving to the home and they benefit from being able to make trial visits. Improvements are needed to the written information given to service users thinking of moving to the home. EVIDENCE: A statement of purpose and a service user guide are available. A new service user had been given a service user guide before moving to the home. The statement of purpose and the service user guide have been reviewed and now contain up to date information about staffing and services. Both documents now also include information about the sizes of communal and bedroom space. Some improvements continue to be needed to the statement of purpose and service user guide. The statement of purpose refers to the home being registered for older people of 60 years and over as opposed to 65. The managers qualification is not accurate. A standard form of contract is needed in the service user guide. The handwritten information could also be typed to give a more professional appearance. Reference is made to practices that Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 10 have not yet been put in place, such as the quality assurance systems. Work is taking place to develop these systems. The manager visits all prospective service users to carry out an assessment before they are offered a place at the home. One new service user 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 service users and although 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 a service user, manager and staff 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 DS0000018882.V288740.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 visiting the service. Staff are aware of the needs of service users and how to meet them, however, staff are not provided with sufficient written information to meet the needs of service users. The health care needs of service users are met. The management of medication in general supports the well being of service users. Service users are treated with respect. EVIDENCE: A sample of service user plans were looked at. These plans identify the current needs of service users but do not provide sufficient information for staff around the action to be taken to meet these needs. For example, some care plans indicate that assistance is needed with washing and dressing, however, the care plans do not clearly state what that assistance is. A discussion took place with the manager and deputy manager around the action that needs to be taken to address this. The staff spoken to, were aware of the needs of the service users whose records were inspected, and how to meet these needs. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 12 It continues to be recommended that the initial assessment undertaken before service users come to live at the home and the service user plan indicate the support service users 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. 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 care is very good” and “we are well cared for.” When asked about the service in general, a service user said “if I had to live outside my own home, this would be one of the places I would choose.” 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 service users. A record is made of visits by health professionals and the outcome is documented. Service users spoken to said that their health needs are met at the home. The records of accidents are held on individual service user files. A sample were seen and were satisfactorily completed. An audit of accidents is now being completed as recommended at the last inspection. Comments received from a GP indicated that they are satisified with the care provided at the home, that any specialist advice is followed and that staff show a clear understanding of the service users care needs. A sample of the medicine administration record (MAR) sheets and corresponding medications were inspected and found to be correctly maintained. Care needs to be taken to ensure that the amount of medication received or carried over is recorded on the MAR sheet so that an audit of medication is available. Staff who administer medication have been trained in the administration of medication by the supplying pharmacist. Some of these staff have also completed training around giving medication as part of an NVQ in care of the elderly. At present, a formal means of assessing whether a worker is competent to give medication is not in place. This must be put in place and a record made in the member of staff’s training file. It is suggested that consultation take 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. Guidelines around the safe storage of oxygen and around the support a service user needs in using oxygen are to be made available for staff. Staff were observed to treat service users with respect. Staff were observed to speak to service users in a respectful manner and knocked at bedroom doors before entering. The service users interviewed said that the staff are “polite,” “friendly,” “helpful” and “kind.” Staff receive guidance on promoting the dignity of service users. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 13 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 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 service users is promoted by the flexibility of the daily routines, visitors being made welcome to the home, the provision of well balanced, appealing meals and by the opportunities for service users to make choices. EVIDENCE: A record of activities is available in the lounge. Armchair aerobics, films, a quiz, and bingo were activities recorded as being available for service users to take part in. The service users spoken with said that they have enough to do at the home. The service users spoken with said that they generally like to keep themselves occupied rather than take part in planned activities. Since the last inspection the manager has spoken with the service users about the activities provided and is planning to make some changes to what is offered. Staff spoken with said that often activities are offered but the service users do not wish to take part. Observations and a discussion with service users indicated that the routines of daily living are flexible. Service users said that the home encourages them to 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 service users Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 14 bedrooms that were seen had been personalised with items brought in from their own homes. Information about advocacy services is available. Service users said they are consulted with about what activities and food they would like provided. The religious needs of service users are met. Several service users attend a local catholic church and clergy from other religions visit the service. Visitors are welcome at the home at reasonable times. Service users can see visitors in private in their bedrooms. A quiet area is available in the dining room. During this inspection, the service users who were spoken with said they felt their visitors are made to feel welcome. At the last inspection, a number of visitors were observed visiting the home during the inspection and were greeted warmly by the staff. Service users confirmed that the food provided was of a good quality and that they are happy with the variety. They also confirmed that they can choose between two meals at lunch time and between several light meals at dinner time. The record of meals shows that there is a good selection of well balanced meals provided. Special dietary needs would be catered for. At present a written menu is not available. The cook and manager reported that meals are planned on a weekly basis in accordance with service users requests. Each day every service user is asked what they would like to choose from the choices available. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 15 Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. 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. Service users are adequately safeguarded. Service users know how to make a complaint. Staff know how to manage complaints and adult protection matters. EVIDENCE: There is a complaint procedure available in the lounge. Although the complaint procedure provides information to service users around how to complain, the procedure is written for staff and indicates how staff are to manage a complaint. The service users spoken with said that if they had a complaint to make they would approach the manager or a member of staff. No complaints were recorded in the complaints record and no complaints have been made to CSCI about the home since the last inspection. Staff spoken to knew how to manage a complaint. A complaints and comments book is situated in the lounge. Since the last inspection a copy of Wirral Metropolitan Borough Council’s adult protection procedures has been obtained. The homes adult protection procedure has also been amended and is satisfactory. 3 staff were interviewed and were very well aware of the procedure to follow should they suspect abuse. It is recommended all information relating to adult protection be stored together for ease of reference. The spelling in the home’s adult protection procedure should be corrected to again, ease reference. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 17 Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 18 Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 19 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 the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. The home is clean and in general, satisfactorily maintained. The safety of service users is in general, promoted. EVIDENCE: Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 20 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 in general, satisfactorily maintained at the time of the inspection. The carpet in the lounge and the decoration in the lounge and dining area are showing signs of wear and tear. The manager reported that these areas have been identified for redecoration and will be attended to within the next 3 months. The attention given to this will be looked at, at the next inspection. The decoration in bedroom 3 would benefit from attention, as there is a worn patch and a rip in the wallpaper. At the time of the inspection, the door to bedroom 4 was catching on the carpet, which had recently been laid. This requires attention. 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 also contribute to ensuring the quality of the service provided. At the time of this inspection a ladder and a commode were stored in the toilet on the mezzanine floor. This would present difficulty in accessing this area. The deputy manager reported that this area does not tend to be used. Appropriate storage arrangements are to be made for these items. At this inspection, a risk assessment was available for a bed rail that is provided to a service user. This provided a satisfactory assessment to safeguard the service user. Care must be taken to ensure that this assessment is regularly reviewed. 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. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including visiting the service. The records of the homes recruitment practices and training provided to staff indicate that service users are not fully safeguarded. Although, service users benefit from staff being encouraged to undertake an NVQ 2 in Care of Older People, they would benefit further from staff completing a formal induction and foundation training programme. The numbers of staff available meets the needs of service users. EVIDENCE: The rota for the week of the inspection indicated that there are a minimum of two staff on duty at all times. Staff indicated that there are always sufficient staff available to meet the needs of service users. Service users said that staff are “helpful” and “kind.” Service users said that when they need assistance the staff are attentive and ready to assist. At the last inspection a requirement was made that a record of whether the rota was actually worked be maintained. This requirement has been met. A number of staff have worked at the home for several years and know the needs of the service users well. This promotes continuity of care. The friendliness of the staff to each other and to service users was commented on by service users at this and previous inspections and was observed on the day of the inspection. This creates a pleasant and relaxed atmosphere within the home. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 22 The manager reported that 5 out of 11 staff, have completed an NVQ 2 qualification in care of the elderly. The records of training supported this. In addition, 3 further staff have been accepted on to an NVQ care of the elderly training course and will begin this training in September 2006. At this inspection, the records relating to the two newest members of staff were seen. A photograph was not available for both staff. 2 references were not available for some staff who have been employed at the home for 12 months or more. The manager reported that all staff receive a brief induction. This covers the home’s policies and procedures, day-to-day routines; service user’s care plans and health and safety issues. Following this the manager reported that further training is provided around meeting the needs of service users and health and safety matters. The manager reported that all staff are then encouraged to complete an NVQ in care of the elderly. A record is not consistently made of the induction training. Since the last inspection, the induction recommended by Skills for Care has been obtained. This is being used to provide induction training to the two new staff. The progress of this will be looked at, at the next inspection. A training programme was not available. At this inspection, the training certificates where available for staff. This indicated 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. All staff must receive training appropriate to the work they perform. During the inspection, the manager arranged for 3 staff to attend food hygiene training. An audit of the training staff have undertaken should be completed to ensure that a plan to meet the training needs of staff can be developed. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 visiting the service. The arrangements for quality assurance and supervision of staff need improvement. The safety of service users is in general promoted. 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 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. At the last inspection records were difficult to find. There has been a general improvement to record storage, however there is room for further work here. A number of files are in the office contain information that is no longer in use. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 24 This makes the current policies and procedures difficult to access. Any documentation not in use should be stored elsewhere. There are 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 questionnaire has been sent to service users and their relatives and the results are being assessed. If an action plan for future development were drawn up this would enable the home to meet the relevant requirement. Additionally a questionnaire for GP’s, district nurses and other visiting professionals would complete the quality assurance process. Service users 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 service users. The financial affairs of service users are managed by the service users themselves, or by their family or a solicitor. Service users are able to bring personal possessions to the home. A requirement was 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, 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. A sample of safety check records was seen for the electricity, gas, portable appliance testing, stair lift and contractors checks of the fire safety systems and were appropriately maintained. The bath hoists service certificates were not available for inspection. The manager reported that only one bath hoist is used and following the inspection provided evidence that this hoist had been serviced. The additional bath hoist must be serviced, as it is currently available for use. Since the last inspection, improvements have been made to records regarding fire safety checks. The records of fire drills and fire safety training provided to staff were up to date, as were the records of emergency lighting tests. A discussion with the manager indicated that verbal guidance around the evacuation procedure is provided to staff, which is not fully recorded in the written evacuation procedure. This is to be addressed. Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 2 Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 26 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 OP1 Regulation 6 Requirement Timescale for action 10/08/06 2. OP7 15 3. OP9 13 4. OP9 13 The registered persons must review the statement of purpose to ensure that it accurately reflects the minimum age of service users that it is registered for. The managers qualification must be accurate. A standard form of contract must be available in the service user guide. The registered person must 10/06/06 ensure that service user care plans contain clear information as to how staff are to meet service users needs (previous timescale of 09/03/06 not met). The registered persons must 10/05/06 ensure that a record of the amount of medication received or carried over is recorded so that an audit of medication is available. The registered persons must 10/05/06 ensure that a formal means of assessing whether a member of staff is competent to give medication is put in place. A record of this assessment is to be made in the member of staff’s DS0000018882.V288740.R01.S.doc Version 5.1 Devonshire Manor Page 27 5. OP9 13 6. OP19 23 7. OP19 23 8. OP29 19 9. OP30 18 10. OP33 24 11. OP36 18 12. OP38 13 training file. The registered person must provide guidelines around the safe storage of oxygen. Guidelines around how to assist a service user who requires oxygen must also be provided. The registered person must provide appropriate storage arrangements for the ladder and commode that were stored in the toilet on the mezzanine floor at the time of the inspection. The registered person must take steps to ensure the door to bedroom 4 opens and closes easily. The registered person must ensure that staff are employed following the receipt of all the required recruitment information as detailed in Schedule 2 and Schedule 4 of The Care Homes Regulations 2001 (previous timescale of 09/03/06 not met). The registered person must demonstrate that all staff have received training appropriate to the work they perform (previous timescale of 09/03/06 not met). The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the home (timescale of 09/06/06 has not expired). 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 of 09/03/06 not met). The registered person must ensure that the fire evacuation procedure covers the guidance provided to staff during the fire safety training. DS0000018882.V288740.R01.S.doc 17/05/06 17/05/06 17/05/06 10/05/06 10/08/06 09/06/06 10/08/06 10/06/06 Devonshire Manor Version 5.1 Page 28 13. OP38 13 The registered person must provide evidence to CSCI that the bath hoist on the first floor is suitable for use. 17/05/06 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 OP7 Good Practice Recommendations 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 the initial assessment undertaken before service users come to live at the home and the service user plan indicate the support service users need to use the stair lift. It is suggested that consultation take place with Skills for Care to ensure that the training provided to staff in the management of medication is appropriate. The complaint procedure should be amended so that it details the process for service users making a complaint rather than how staff are to manage complaints. It is recommended all information relating to adult protection be stored together and that the homes adult protection procedure contain correct spelling so as to ease reference. 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. The decoration in bedroom 3 would benefit from attention, as there is a worn patch and a rip in the wallpaper. An audit of the training staff have undertaken should be completed to ensure that a plan to meet the training needs of staff can be developed. The induction and foundation training is to meet all of the National Training Organisation targets. The registered manager is to complete an NVQ Level 4 in care. Any documentation in the main office that is not in use should be stored elsewhere. DS0000018882.V288740.R01.S.doc Version 5.1 Page 29 3. 4. 5. OP9 OP16 OP18 6. OP19 7. 8. 9. 10. 11. OP19 OP30 OP30 OP31 OP33 Devonshire Manor Devonshire Manor DS0000018882.V288740.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 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 DS0000018882.V288740.R01.S.doc Version 5.1 Page 31 - 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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