This inspection was carried out on 24th October 2005.
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. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Devonshire Manor Care Home 2 Devonshire Road Sherwood Nottingham NG5 2EW Lead Inspector
Stephen Benson Unannounced Inspection 24th October 2005 09:30 Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 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 Care Home DS0000002196.V261744.R01.S.doc Version 5.0 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 Adults 18-65. 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 Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Devonshire Manor Care Home Address 2 Devonshire Road Sherwood Nottingham NG5 2EW 0115 962 2538 0115 9856111 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) Mrs Margaret Ann Webster Joanne Tatia Ault Eric Foster Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. People accommodated will have suffered a head injury. People accommodated will be aged 18 or over. Date of last inspection 08/06/05 Brief Description of the Service: Devonshire Manor is a care home providing personal care and accommodation for 5 younger adults who have disabilities resulting from a brain injury. The home provides short and long term care and will provide a respite service and accept emergency admissions. The home is owned by Stepforward (Nottingham) which is run as a family business. The home is located in a residential area of Sherwood close to shops, pubs, the post office and other amenities. The home was opened in 1987 and consists of a domestic dwelling with a small extension to the rear. All of the home’s bedrooms are single, and none of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors. The home does not have a lift. The home has a small tarmac courtyard and there is car parking available for 2 cars with further unrestricted parking available on the road. Further information about the home can be obtained from the manager. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection lasted for 3 hours and the inspection focussed on key standards not inspected at the last visit and the requirements that were set. The main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, care staff on duty and care practices were observed. No visitors came to the home during the period of inspection. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: What has improved since the last inspection?
The care planning system has been worked on and is now more organised making it easier for staff to use. Residents said that staff discuss their care plans with them. The home has become non-smoking and the old smoke room is being converted into a staff room. A seating area has been put outside with a blind over and this is now the designated smoking area. There has been some decorating done to the outside of the home. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents are assessed prior to admission. EVIDENCE: There was a requirement set at the previous inspection to obtain a copy of a community care assessment for a recently admitted resident. A copy of this assessment was seen on the residents file and the manager said that he would ensure that an assessment is obtained prior to any future admission. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Care plans will be more effective as a result of being better organised. EVIDENCE: There was a recommendation set at the last inspection to keep care plans in a more organised manner. An order for plans has been developed and one plan set up as an example for staff to follow. This includes creating subject sections, indexing plan and having separate sheets to record all medical appointments on. Staff said they were pleased with the new system and it will make plans much easier to use. Residents said that they talk about their care plans with staff. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The way complaints are dealt with is improving. EVIDENCE: There was a requirement set at the last inspection to ensure that complaints made are addressed through the complaints procedure. A discussion was seen taking place between a member of staff and a resident about a complaint. Residents said they can tell staff anything they are not happy with. The manager said that he had purchased a new book to record any complaints in. The manager identified recognising and dealing with complaints as an area he intends to develop. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The changes being made to the rear of the home will benefit the running of the home. EVIDENCE: There were requirements set at the last inspection to review the current layout/use of the rear extension, decorate external paintwork where needed and to provide seating for residents in the courtyard area. The rear extension is in the process of being changed from a smoking room into a staff room and the home is now a no smoking environment. A seating area has been provided in the courtyard with a blind above for shelter. This is the area used by those wishing to smoke. Residents said it didn’t bother them having to go outside to smoke unless it is raining. The external paintwork has been attended to where needed. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Training records do not show the skills ands expertise of staff. EVIDENCE: Arrangements are in place for staff to undertake National Vocational Qualification training and those newer staff who have not yet registered on a course are having a meeting to look at their options. There is not an up to date record of training undertaken by staff and information was not readily available as to when staff were due updates on their training. A course on control and restraint has been arranged for later in the month. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 More needs to be done to seek views of residents on the services provided. The home’s polices and procedures need to be reflect the home. EVIDENCE: A recommendation as made at the last inspection that the manager should enrol onto either the Registered Manager Award or National Vocational Qualification level 4. The manager has made enquires about these courses and is currently looking at funding options. Requirements were set at the last inspection that the provider must prepare reports as detailed in Regulation 26 and the views of residents and relatives should be sought on the services provided. These have not been complied with and are repeated in this report and must be met. The homes policies and procedures have been prepared at another home owned by the same providers. These have not been adapted to reflect this home and should be signed and reviewed by the manager.
Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 16 The fire log showed that weekly tests have not been carried out on the fire alarm for the past month and the emergency lighting has not been tested since July 2004. Residents said the fire alarm had gone off the previous day. There was no record of this in the fire log and residents had not evacuated the building as described as the action to be taken in the home’s fire safety policy. The fire alarm had not been properly reset and was disengaged. There was no record of a fire drill being held recently. There are contracts in place to ensure that the required gas and electrical safety checks are carried out. Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Devonshire Manor Care Home Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 1 X X 2 x DS0000002196.V261744.R01.S.doc Version 5.0 Page 18 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 3 4 Standard YA32 YA39 YA39 YA40 Regulation 18 26 24 18 Requirement Keep up to date training records of all training undertaken by staff The provider must prepare reports as detailed in Regulation 26 Seek the views of residents and relatives on the services provided Ensure that policies and procedures are prepared for the home and signed and reviewed by the manager Ensure all fire safety checks are carried out and that the correct procedures are followed in the event of a fire alarm Ensure all staff know how to reset the fire alarm ands arrange for a fire drill Timescale for action 01/01/06 01/12/05 01/02/06 01/01/06 5 YA42 23 01/11/05 6 YA42 23 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
DS0000002196.V261744.R01.S.doc Version 5.0 Page 19 Devonshire Manor Care Home Standard Devonshire Manor Care Home DS0000002196.V261744.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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