Inspection on 29/06/05 for Devonshire, The

This inspection was carried out on 29th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Devonshire, The 03/05/07

Devonshire, The 06/12/05

Devonshire, The 29/11/04

Devonshire, The 05/10/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE The Devonshire 213 Malden Road New Malden Surrey KT3 6AG Lead Inspector Diane Thackrah Unannounced 29th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Devonshire Address 213 Malden Road, New Malden, Surrey, KT3 6AG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8949 0818 020 8949 2383 Mrs Annar Mangalji Mrs Jean Loughran Care Home 31 Category(ies) of Dementia - over 65 years of age (3), Old Age, registration, with number not falling within any category (28) of places The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 29t November 2004 Brief Description of the Service: The Devenshire offers residential care to thirty-one older people. The home is situated with easy access to the A3, New Malden High Street and public transport. Accomodation is provided over three floors, all of which are serviced by a passenger lift. There is a large communal lounge and dining area, a library, a well maintained patio area and all bedrooms are for single occupancy. Corridors are wide and there is appropriate equipment such as grab rails and specialist baths. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 29th June 2005 between 09.40 and 11.30. Care records were examined and a partial tour of the premises took place. A number of service users were spoken with, as were staff members and the Registered Manager. From observations and discussions with service users, it is concluded that service users are well cared for. What the service does well: Full information about what services are on offer in the home are provided in a statement of terms and conditions, ensuring that service users have an opportunity to exercise choice about whether to live in the home. There is consultation with service users about their changing needs. This ensures that the home continues to meet these needs. Feedback from both service users and their relatives is that staff members have the skills and personal qualities to meet their needs. Service users have their privacy respected; their dignity upheld and are consulted with about the things they want. Activities are varied and are chosen by service users. Food is of a high quality. There are good opportunities for service users to maintain contact with their families and friends. The home is well maintained, homely and decorated to a high standard. Service users bedrooms reflex their individual preferences and contain their personal possessions. The Registered Manager listens to the views of those who live in, work in, and visit the home. Health and safety in the home is taken seriously. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 4. Information about the home is provided in statements of terms and conditions, allowing service users to know facilities provided and what they are paying for. There are a range of services available that allow service users to have their needs met. EVIDENCE: The Registered Manager said that each service user is provided with a statement of terms and conditions at the point of moving into the home. There was a signed statement of terms and conditions available for the newest admission to the home. From observations and discussions with service users, it is evident that the home is able to meet the needs of the current service user group. At the time of this inspection service users presented as being relaxed, and those spoken with said that they were happy in the home. There was feedback in letters and ‘thank-you’ cards to the home from relatives and service users. These were all very positive about the service provided by the home and the high level of care provided by the staff team. Comments included “All staff members do an excellent job” “Thank you for the friendliness and kindness of the staff” The The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 9 personal records of one service user were examined. These detailed that individualised needs had been addressed. Observation of staff members and staff training records indicate that staff members have the skills and abilities required to meet the needs of service users. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 10 The home has a philosophy of care that is based on treating service users with respect and preserving their dignity. EVIDENCE: There was a relaxed and homely atmosphere in the home. Staff members were observed to share respectful relationships with service users during this inspection. Staff members consulted with service users and allowed them to make their own decisions. Staff members were also observed to knock, and wait for a response before entering bedrooms. There were locks on bathroom and toilet doors. There was documentation in one service user’s file detailing that they, and their relatives had been consulted about a wide range of daily living arrangements. The staff induction programme covers how to treat service users with respect, and how to uphold their dignity. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. There are varied activities and wholesome and enjoyable meals provided. Service users are consulted about meals and activities and therefore differing expectations and lifestyles are well catered for. EVIDENCE: The daily routine is varied and flexible and there is a very good programme of activities. An activities calendar for June was displayed in the lounge. Information about activities is also made available to service users and their families in a monthly newsletter. Activities that have occurred this month have included ‘bend and stretch’, darts, afternoon films, fresh air drives and musical bingo. Residents meetings are held regularly. Minutes of these meetings detail that service users have opportunities for discussing and planning activities. One service user had commented “I enjoyed the karaoke” One staff member said that a BBQ had been held the day prior to this inspection, and that the majority of service users had attended, and enjoyed this. Newspapers are purchased daily by the home, and regular ‘news’ discussion groups are held. During this inspection a group of service users were participating in a quiz in the main lounge. Other service users were noted to be spending time in their bedrooms, or chatting with staff members. There is a library on the top floor of the home with a large selection of large print and talking books, and videos. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 12 The home has an open door policy and family members and friends are encouraged to visit. There are good opportunities for service users to exercise choice on an ongoing basis. The home has also been proactive in acquiring the views and wishes of service users through facilitating residents meetings, residents council meetings and satisfaction surveys. Bedrooms viewed were homely and had been personalised with service users own possessions. There was a weekly menu available that detailed that meals provided are varied, and that a choice is always available. A lunch of roast chicken and fresh vegetables was being prepared during this inspection. Fresh, wholesome and nutritious food was available in the kitchen. Good efforts have been made for ensuring that service users eat balanced and healthy meals. One staff member said that hot and cold drinks are provided throughout the day, and on request. Meals can be taken in bedrooms, or the pleasant, communal dining area. As a way of maintaining and improving the quality of meals, three service users are asked to complete a satisfaction survey following each meal provided. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16. There is a system in place for the effective handling of complaints and service users and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon EVIDENCE: There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a complaint may be made to the Commission for Social Care Inspection. This information is also made clearly available in the entrance hall of the home. The Registered Manager said that service users and their relatives are encouraged to raise any concerns with staff members before they become problematic. No complaints have been made about the home since the last inspection. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24 and 26. The home is, maintained, decorated and furnished to a high standard and facilities are clean and safe. This ensures that service users live in a pleasant, homely and comfortable environment. EVIDENCE: The home is a large detached property, situated on a main road close to New Malden High Street. There is a large car park at the front of the property, and a well maintain paved garden to the rear. The grounds and garden were tidy and safe and accessible to service users. The home was decorated and furnished to a high standard and there is a routine programme of maintenance and redecoration. The home is laid out over three floors, accessed by lift or stairway. The Registered Manager said that the local fire officer has not visited the home recently. However, it was noted that precautions have been taken throughout the home to reduce the risk of fire, and that a risk assessment is in place. The local environmental health officer has recently visited the home. Generally, The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 15 requirements regarding environmental health have been met, however, this visit highlighted the need for additional training in food hygiene for all staff members. Toilets and bathing facilities are provided on each floor of the home. These facilities are accessible and provide privacy. In addition, each bedroom has en suite facilities. Adaptations have been made to various areas of the environment to ensure the health and safety of the service users. There are specialist baths and hand rails are in place on the staircase and corridors. Any adaptations or specialist equipment that is needed for service users is assessed by an occupational therapist on an individual basis as and when needed. Bedrooms are furnished and equipped to assure comfort and privacy. The home was found to be very clean and free from offensive odours. The laundry is sited in the basement, well away from the kitchen. The home has a contract for the collection of clinical waste. The washing machine has a sluice facility. Policies and procedures are in place to deal with the safe handling of clinical waste. Staff members receive in house infection control. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28. The numbers and skills mix of staff members are sufficient to meet the needs, and ensure the safety of the current service user group. EVIDENCE: Staffing levels were found to be appropriate and safe, in accordance with the care and social needs of the service users. There are three care staff members on shift during the day and two staff members on shift through the night. There are two housekeepers, a laundry worker, a cook, a maintenance worker and administration staff. The Registered Manager said that all staff members are trained to carryout care work. This ensures that existing staff members can cover holidays, sickness and annual leave so that service users are cared for; in general, by people they know. Feedback from one service user was that staff members were helpful. There were minutes of a resident’s meeting detailing that another service user thought that staff member were “wonderful” Three staff members currently have a qualification at NVQ Level 2 in Care. An administration worker is undertaking an NVQ qualification, and the Registered Manager is undertaking the NVQ Level 4 in Management Award. However, the home is not on target to having at least 50 of the staff team being qualified at NVQ Level 2 in Care by the end on 2005. The Registered Manager said that difficulties have been experienced in accessing an NVQ assessor. A recommendation is made, in line with the intentions of the home, that further care staff members undertake this qualification. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 17 The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 36 and 38. There is a competent manager who fosters an air of openness and provides good guidance. Service users are therefore valued, and cared for by a competent staff team. Good health and safety practices ensure that service users are live in a safe environment. EVIDENCE: Both staff members and service users were noted to enjoy respectful and open relationships with the Registered Manager. There was feedback from family members in letters to the home that detailed that they had felt supported by the Registered Manager. Staff members spoken with said that they received good support and guidance. As well as being available in the home for informal discussions, feedback about the service is gained in resident and staff meetings. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 19 The Registered Manager is responsible for providing formal supervision to all staff members. Records of regular supervision sessions were available for inspection. There are good arrangements for ensuring safe working practices in the home. Detailed, six monthly health and safety audits are carried out in the home. All staff members undergo training in safe working practices and safety procedures are posted throughout the home. All services, equipment and facilities are maintained in a safe state to ensure the use and safety of the service user and staff. Risk assessments of the premises and the individuals are in place for their protection. All accidents and incidents are recorded, and safety procedures are in place. There were records detailing that gas appliances in the home had been serviced in March 2005 and the gas system had been serviced in July 2004. The lift is serviced regularly, a legionella test has recently been carried out and an electrical installation inspection was carried out in May 2005. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 x 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 x x x 3 x 3 The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 21 No. 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard 28 Good Practice Recommendations The Registered Person should ensure that further efforts are made for ensuring that at least 50 of care staff members have the NVQ Level 2 in Care qualification by the end of 2005. The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 22 Commission for Social Care Inspection CSCI 8th Floor Grosvenor House 125 High Street, Croydon CR0 9XP 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 The Devonshire G53-G53 S13384 devonshire V235736 290605 stage 0.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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