Inspection on 03/05/07 for Devonshire, The

This inspection was carried out on 3rd May 2007.

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 06/12/05

Devonshire, The 29/06/05

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 Devonshire, The 213 Malden Road New Malden Surrey KT3 6AG Lead Inspector Jon Fry Key Unannounced Inspection 11.35a 3 and 10th May 2007 rd 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, The DS0000013384.V338490.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, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Devonshire, The Address 213 Malden Road New Malden Surrey KT3 6AG 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) 020 8949 0818 020 8949 2383 Mrs Annar Mangalji Mr Abdul Majid 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 other category (28), of places Physical disability (1) Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One specified female under the age of 65 until her 65th birthday when condition will cease. To allow the Devonshire to use the library room as bedroom for a period of four weeks from the 28th April 2003. One (1) place for a service user under the age of 65, with a physical disability, can be accommodated. 1st June 2006 Date of last inspection Brief Description of the Service: The Devonshire provides residential care for thirty-one older people. The home is situated close to New Malden High Street with good access to public transport and the A3. Accommodation is provided over three floors that are served by a passenger lift. There is a large communal lounge and dining area, library and a well maintained patio / garden area. All bedrooms are single. The current range of weekly fees is £475 to £675. Additional charges are made for newspapers, hairdressing, toiletries and routine hospital visits over two hours in duration. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector who spent twelve hours in the home over two separate visits. The inspector talked individually with twelve people living at the home. Three relatives or friends of individuals were also spoken with during the inspection. A number of records were examined and discussions took place with the owner, the manager and five staff members. Completed surveys were received from seven people living at the service and three relatives or friends of individuals. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be reviewed. Individual support needs need to be clearly stated with specific and personalised information recorded on how they are to be met. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 6 Staff providing activities should be provided with specialised training around this very important area of care. 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, The DS0000013384.V338490.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. People who use the service experience good quality outcomes in this area. Good information is available to prospective users of the service about the home. Assessments are completed before people move in to make sure that their individual needs can be met. EVIDENCE: “It’s a good place”, “it’s done pretty well” and “I’m well looked after” were some typical comments from people living at the home. Relatives and friends comments included “very nice” and “overall very satisfied”. One relative said that both they and their mother had been able to visit before making a decision about moving in. Residents who completed surveys all said that they received enough information before they moved in. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 9 A guide to the home is available which contains good quality information about the service it provides. This is available electronically as well as in large print if requested. We recommend that other formats are looked at for the guide such as tape or pictures to make sure that it can be used by as many people as possible. We saw that there is an admissions procedure and that assessments are completed prior to anybody moving in. Once an individual comes to live there, a care plan is written based on these assessments. A written contract is provided to people who live at the home and / or their representatives. It is recommended that these documents are also made available in other formats as required. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. Medication is managed very well and individual health care needs are fully addressed. Care plans need to be improved to be more person centred and to fully address all the needs of people using the service. EVIDENCE: People using the service that we spoke to all said that staff were polite and treated them with respect. Comments included “they do their best”, all friendly and kind” and “they are very nice”. We looked at care plans for three people. The service draws up a care plan for each person and reviews this regularly to make sure it’s up to date. The plans could however be improved to contain better quality individualised information for each person. Specific detailed information about how individuals like support to be provided to them needs to be recorded. This will help to enable all care staff to give high quality personalised care to people living there. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 11 The social needs of individuals need to be included as an important part of the care planning. We saw that the home had begun to address this area in the care plans at the time of this inspection. The monthly reviews of these documents can then be used to inform the homes activities programme. It is recommended that the staff team look at the content of the daily notes they are keeping to make sure they are recording good quality information. Some of the notes we saw were repetitive and lacked enough detail to be of use when assessing the care being delivered to individuals Health needs are being met. Records kept showed that people can see a GP or other healthcare professional when they need to. Community nurses visit the home as required by individuals. Residents who completed a survey all said that they received the medical support they need. One relative said that that a recent medical emergency had been “dealt with extremely well”. Medication is managed very well. We saw that items of medication are securely stored and given to individuals by trained staff at the right time with full records kept. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 12 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. People who use the service experience good quality outcomes in this area. The home offers a good range of activities. There is scope to improve this further by developing an individualised social care plan for each person living there. Feedback about the food served was mixed and therefore this part of the service requires further review. EVIDENCE: Feedback from people living at the home about the food was mixed. Comments included “very good”, “good”, “adequate”, “its ok” and “its alright”. Other people said “it has been cold when I’ve got it”, its cold and tough” and “sometimes it’s very good, sometimes it’s not so good”. These comments were fed back to the owner and the manager at the time of the inspection. The service has its own quality assurance system and looks at feedback from individuals on a weekly basis about the meals provided. We have recommended that the home looks at meal times as part of its ongoing development given the mixed feedback received. This should also include reviewing how menus are presented to the people living there and the Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 13 choices they receive at each mealtime. The current use of bibs or tabards at meal times for a small number of people living there should additionally be looked at to see if there is a better and more dignified alternative. There is a strong programme of social and recreational activities with dedicated staff to provide these. Daily activities provided include fresh air drives, beauty salon, bingo and daily news. Photographs of past activities and trips are displayed around the home and a monthly newsletter is put together by the home providing news and information to the people living there. Feedback from individuals included “I usually go on the trips out”, “the hairdresser is very nice” and “I enjoy the fresh air drives best”. Other feedback included “would enjoy more than we have” and “not much entertainment”. A personal profile is kept of each person living there and this gives very good information on their personal history and individual likes and dislikes. As stated previously in this report, it is important that care plans are developed for each person around the their social needs. This will help to review and develop the activities programme further. The two staff responsible for activities need to attend specialised training in this area to help them continue to develop the programme provided. All individuals spoken to said that they were able to have visitors whenever they liked. Comments from relatives or friends included “I am made welcome” and “always welcoming and helpful”. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 14 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. People who use the service experience good quality outcomes in this area. Individual concerns about the care provided are listened to and acted on. People living at the home are protected from abuse. EVIDENCE: Records are kept of any complaints received and the manager reported that there had been no recent complaints about the service. Information about how to make a complaint is displayed at the home and is part of the guide provided to people living there. All seven individuals who completed surveys said that they ‘always’ knew how to make a complaint. Three relatives or friends of residents also stated that they knew how to raise a concern or complaint. Comments included “I feel able to approach staff if there are any issues” and “they deal with any issues”. Care staff at the home have training that teaches them how to recognise and report abuse. Staff have procedures they can follow in the event of any allegations being made to them. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 15 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. People who use the service experience good quality outcomes in this area. Individuals who live at the home enjoy a comfortable and safe living environment. The premises are well maintained and kept to a good standard of cleanliness. EVIDENCE: Individuals spoken to said “very nice”, “very happy with my bedroom” and “comfortable”. All seven surveys received from individuals said the home is ‘always’ fresh and clean. We saw that it was clean and hygienic during this inspection. The home provides a comfortable and well-maintained living environment for the people living there. The service employs a maintenance person and we saw that they were busy re-decorating some areas when we visited. A number of individuals spoke very highly of the maintenance person and the time they Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 16 spent chatting with them on a regular basis. The home has an ongoing programme of refurbishment with finances provided to support this. Bedrooms are individualised to resident’s preferences. Residents are able to bring personal items, including furniture, with them on admission and are able to have a private telephone line. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 17 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. People who use the service experience good quality outcomes in this area. People living at the home are protected well by the home’s recruitment procedures. There is a staff training and development programme that provides staff members with skills necessary for meeting the needs of service users EVIDENCE: Feedback about the way the staff carried out their duties was very positive. “They do everything they can”, “very good” and “we have a little laugh and joke” were typical comments from individuals. We saw that staff interacted well with people and these relationships appear very positive. Relatives and friends of residents said “staff are very caring” and “friendly and kind”. There was however mixed feedback about the availability of staff. Comments from people there included “they do their best but could do with more staff”, “not enough of them” and “sometimes enough, sometimes not”. Other individuals said “they do their best” and “sometimes can’t find enough of them”. Relatives or friends of people made comments such as “usually enough staff” and “there aren’t so many staff around” Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 18 The layout of the home does seem to contribute to the impression that there are not so many staff around. We saw that staffing levels were satisfactory for the needs of people living there. On both days we visited there were four care staff on shift along with the manager, an activities co-ordinator, the maintenance person and two administrators. It is however strongly recommended that the home keeps the staffing under review and continues to talk with people who use the service about this issue. We looked at the recruitment records for three members of staff. These were very well maintained and contained all the necessary checks including Criminal Records Bureau (CRB) checks. Staff are offered training in a number of topics such as dementia, medication, fire safety, death, dying & palliative care, and Protection of Vulnerable Adults. NVQ training is also available to staff. Specialised training needs to be made available to the staff organising activities to develop their own good practice. Further training around person centred care and care planning may be necessary for care staff to develop in these areas. Individual staff spoken to said that they received regular supervision with their line manager and received the training they needed to do their jobs. NVQ training is also available to staff. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 19 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. People who use the service experience good quality outcomes in this area. The service is run and managed by competent and experienced individuals. There are good arrangements to make sure that the health and welfare of people using the service is protected. EVIDENCE: Relatives or friends of people living at the home we spoke to said they felt able to speak to the manager about any issues they had and were confident that these would be dealt with. Care staff spoken with said that they received the support and guidance they needed through training and regular supervision sessions. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 20 We saw that Health and Safety records are generally well kept by the service. We found one instance where a safety check of a hoist being used by care staff was overdue. This was addressed by the home immediately and this check took place soon after the inspection visit. The home is introducing its own quality assurance system and this was seen to be very comprehensive in what it looks at. We saw that individuals are asked about the way the home is run and the quality of care provided. Residents meetings are held regularly and minutes are kept of these meetings. It is recommended that actions required following each meeting are added to the minutes and signed off by the manager. These can then be used to make sure that the views of individuals are listened to and acted upon. Letters of compliment were seen and included comments such as “with our thanks for your friendliness and helpfulness ” and thanking the home for “the love and care you gave”. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 21 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 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 (1) 16 (2) (m) Requirement In order to make sure that the service is fully meeting individual needs, care plans must contain specific detailed information about how all their health, personal and social needs are to be addressed. To further increase social opportunities for people living at the home, suitable training must be provided to the two members of staff responsible for the activities programme. Timescale for action 01/11/07 2. OP30 18 (1) (c) 01/10/07 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. 3. Refer to Standard OP1 OP2 OP7 Good Practice Recommendations The guide to the home should be made available in other formats such as audiotape or pictures. The contracts provided by the home should be made available in other formats as may be required. It is recommended that the staff team look at the content DS0000013384.V338490.R01.S.doc Version 5.2 Page 23 Devonshire, The 4. OP15 5. OP27 6. 7. OP30 OP33 of daily notes to make sure that useful and good quality information is being recorded. The home should look at meal times as part of its own quality assurance system. This would include the choices given to individuals and how menus are presented. The use of bibs or tabards should also be reviewed. It is strongly recommended that the staffing levels and their deployment within the home be kept under review. People who live at the home need to be regularly consulted about this issue. The provision of care planning and person centred care training for care staff should be considered. Actions as required from meetings involving people who use the service should be documented and signed off by the manager. Devonshire, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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, The DS0000013384.V338490.R01.S.doc Version 5.2 Page 25 - 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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