Inspection on 06/12/05 for Devonshire, The

This inspection was carried out on 6th December 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 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 Diane Thackrah Unannounced Inspection 6th December 2005 11:15 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.V270948.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 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.V270948.R01.S.doc Version 5.0 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 Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 29th June 2005 Date of last inspection Brief Description of the Service: The Devonshire 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. Accommodation 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. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 6th December 2005 between 11.15 and 15.55. 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, the Registered Manager and a visitor. What the service does well: All service users spoken with expressed their satisfaction with the home. One service user said that the staff were “lovely ” another service user said “I am very comfortable here” Feedback received by the home in letters from the relatives of service users detailed that staff members provided “loving care” in a “cheery way” One visitor spoken with said “I have no problems with the home” Needs assessments are carried out before service users move into the home so that staff members are clear about the needs of each service user. Service user’s spoken with confirmed that staff members were able to meet their needs well. Service users are consulted with about daily living, and things that affect them. There are very good opportunities for social and recreational activities, and individual preferences are respected and catered for. Minutes for service user meetings highlighted that service users choose what activities are to be provided. The home is well maintained, clean, comfortable and homely. Bedrooms are safe and one service user said, “I enjoy spending time reading in my bedroom” Another service user said, “My bedroom is nice and warm” There is good leadership and guidance for staff members, and a training programme that allows staff members to do their jobs well. Service users and their representatives have a say in how the home is run. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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.V270948.R01.S.doc Version 5.0 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 the following standard(s): 3 and 4. There are good arrangements for ensuring that service users have their needs fully assessed prior to them moving into the home. This ensures that service user’s needs are met. EVIDENCE: There was a written needs assessment in place for the most recent admission to the home. The needs assessment was detailed and included information about the health, personal and social care needs of the service user. Risk assessments had been completed as part of the assessment and there was a record of the medication being taken by the service user. In addition, there was a ‘Norton Scale’ risk assessment in relation to pressure sores. A social history had been compiled which included information about the service user’s childhood memories, family history and hobbies. This is good practice. The service user’s relative had signed assessment documentation. There is a key worker system in place that allows service users individual needs to be addressed. Staff members spoken with demonstrated a good awareness of the individual needs of service users. All service users spoken Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 9 with expressed their satisfaction with the home. One service user said that the staff were “lovely ” another service user said “I am very comfortable here” Feedback received by the home in letters from the relatives of service users detailed that staff members provided “loving care” in a “cheery way” One visitor spoken with said “I have no problems with the home” There is a varied activities schedule and a strong emphasis is placed on supporting family members to remain in contact with their relatives. It was noted during this inspection that four service users were using wheelchairs that did not have footrests. Following discussion with the Registered Manager, footrests were provided on these wheelchairs. It is recommended that all staff members receive training in the correct use of wheelchairs in order that service users remain comfortable and safe when using a wheelchair. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10. There are good arrangements for planning for care. This ensures that the individual health, personal and social care needs of service users are well met. EVIDENCE: Individual service users have a plan detailing how staff members should address their needs. Service User Plans for two service users were examined. These set out in detail how staff would meet all aspects of their needs. There were daily observation notes that indicated that staff members provided care in accordance with Service User Plans. Service User Plans detailed how staff members should observe dignity and privacy. One detailed that a service user liked to ware make up and have their hair cut regularly. Also, that they liked to have their bedroom door opened during the daytime, and ajar during the night. From discussion with staff members, it was evident that they were aware of service user’s individual needs, and how these should be addressed. A service user spoken with said that staff members were able to meet their care needs. They reported that staff members leave the buzzer close by so that they can contact staff at anytime. Care plans had been reviewed. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 11 Each service user is registered with a General Practitioner as part of the admissions process. Files examined contained contact details of General Practitioners. General Practitioner’s are contacted, and visit service users in the home at regular intervals. The home liaises with a number of health and social care professionals in order to promote and maintain the health of service users. The Registered Manager said that the home has a good relationship with the local community nurses. Community nurses saw a number of service users during this inspection and there were records detailing that community nurses see one service user on a regular basis. This service user had been provided with a pressure relieving mattress and cushion. There are policies and procedures in place for ensuring that medication is handled safely. Medication Administration Records examined were accurate and up to date. The Registered Manager said that in-house audits of medication handling occur on a regular basis. There was a record of all staff members who had received training in the safe handling of medication. All medication was noted to be stored securely at the time of this inspection and medication prescribed to service users was available. The pharmacist carries out regular checks on medication systems in the home. There are also yearly checks carried out by ‘Boots’ the most recent of these checks was carried out in April 2005 and a report detailed that no problems were identified. Staff members have access to information about a range of medication used in the home. There has been consultation with each service user’s General Practitioner regarding the safe use of home remedies. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Social activities are well organised and provide stimulation for service users. Service users are given opportunities for exercising personal choice and therefore retain some control over their lives. Meals are nutritious and balanced and offer a healthy and varied diet for service users. EVIDENCE: Service users have good opportunities for social and recreational activities. Records indicate that staff members are proactive in finding out how service users want to spend their time, and arranging activities in line with their views. Photographs displayed around the home showed that service users have been on a recent coach trip to ‘Littlehampton and had attended a BBQ in the home’s garden. There were also photographs of a service user’s 100th Birthday celebrations in the home. There is a cosy library on the top floor of the home and a large selection of talking and large print books. One staff member said that the mobile library also visits the home on a monthly basis. Some service users have a television and telephone in their bedrooms and some have newspapers delivered to the home. A monthly newsletter is put together by the home and made available to all service users, their friends and relatives. The newsletter provides details about what activities have, and are scheduled to occur. There are regular residents meetings. The most recent meeting was held a week prior to this inspection and minutes detailed that nineteen service Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 13 users had attended the meeting. Service users had been able to discuss issues such as meals, activities and staffing at the meeting. The wishes of those who choose not to partake in organised activities are respected. Visiting times are flexible and there are places to meet in private. Care notes examined highlighted that service users see visitors regularly in the home. There was a weekly menu available that detailed that meals provided are varied, and that a choice is always available. Fresh, wholesome and nutritious food was available in the kitchen. A lunchtime meal of roast pork or omelette and fresh vegetables was served during this inspection. Staff members were available throughout lunchtime and provided appropriate support. Service users were consulted with about what they wanted to eat. A vegetarian meal is provided for two vegetarian service users. Positive comments were received from service users about meals served in the home. Hot and cold drinks were served throughout this inspection. Bedrooms viewed had water jugs. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. 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. Arrangements are in place for handling allegations and instances of abuse. This ensures that service users will be protected from harm. 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. The Registered Manager said that service users and their relatives are encouraged to raise any concerns with staff members before they become problematic. The home has a copy of the Royal Borough of Kingston Upon Thames vulnerable adult protection procedures. The Registered Manager assured the inspector that there have been no allegations of abuse made within the home in the past year. Staff members receive training in the protection of vulnerable adults as part of the induction programme. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26. The home is 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 home was decorated and furnished to a high standard and there is a routine programme of maintenance and redecoration. There was a maintenance person working and a number of areas in the home were being repainted at the time of this inspection. The Registered Manager said that there are plans to redecorate the whole building. Bedrooms viewed were naturally ventilated with windows conforming to recognise standards. There is central heating throughout the home, and radiators can be adjusted in individual bedrooms. Pipe work and radiators are covered and lighting is domestic in nature. Thermostatic valves are fitted on Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 16 all hot water outlets in bedrooms, communal toilets and bathrooms. Water distributed from a random sample of outlets throughout the home was found to be at a temperature close to 43 degrees. There were records detailing that water temperatures are checked to reduce any risk of scalding. Emergency lighting is provided throughout the home. There was a risk assessment in one service user’s personal records assessing potential risks when in their bedroom. Service users are provided with a key to their bedroom if this is their wish and there is a lockable cupboard in each bedroom. Three service users spoken with said that they were happy with their bedroom. One service user confirmed that the heating in their bedroom was adequate. All bedrooms viewed had been personalised and looked comfortable and cosy. The home was found to be clean and free from offensive odours and there was cleaning staff members on shift. The laundry is appropriate, there is a contract for the collection of clinical waste and the washing machine has a sluice facility. Arrangements were in place for the installation of a new washing machine and tumble dryer at the time of this inspection. Staff members receive infection control training. Service users spoken with confirmed that they were satisfied with hygiene standards in the home. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. There is a staff training and development programme that provides staff members with skills necessary for meeting the needs of service users. EVIDENCE: There were four care staff members, along with a cook, cleaners, a maintenance worker, administrators and the Registered Manager on shift at the time of this inspection. This number appeared appropriate and safe, in accordance with the care and social needs of the service users. Comments from service users were that there were enough staff members to meet their needs. Staff recruitment files were examined for four staff members employed in the home since the last inspection. One file contained all information and documentation required by Regulation. One file contained all information and documentation required by Regulation, other than a recent photograph. Two files did not contain written references, or Criminal Records Bureau and Protection of vulnerable adults checks that had been applied for directly by the home. The Registered Manager said that written references had been obtain, but she could not located them. She also explained that Criminal Records Bureau and Protection of vulnerable adults checks had been applied for, but after more than nine weeks, had not arrived. Additionally, no pre recruitment Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 18 checks had been carried out on a cleaner. There must be no staff member working in the home until all documentation detailed in Schedule two of the Care Homes Regulations has been obtained. The Registered Manager stressed that staff members without sufficient pre recruitment checks would be taken off the rota and would not work in the home until all information had been obtained. Four care staff members have been signed up to undertake ‘Fast Learning’ training of NVQ Level 2 in Care. Four care staff members currently have this qualification. The home also has an induction and foundation programme that is in line with skills for care specifications. The Registered Manager reported that fifteen staff members are scheduled to undertake Infection Control, Nutrition and Health and Health and safety training. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35. The home is managed properly and staff members receive guidance, which allows service users to receive consistent and quality care. EVIDENCE: The Registered Manager has worked in this home for a number of years; she has proved to be competent and skilled in managing the home. There is an atmosphere of openness and respect. She has completed the NVQ Level 4 in Management qualification since the last inspection of the home. There is a quality assurance programme. Service users attend regular meetings, and are canvassed about their views on the home. The Registered Manager said that all relatives and service users are provided with a regular questionnaire and that the Registered Provider collates the results of these surveys. She also confirmed that there is a business plan for the home. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 20 The home does not deal with service user’s money. Service users, or their representatives retain this responsibility. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 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 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 OP29 Regulation 19 (1) 2 Requirement The Registered Provider must apply for, and be in reciept of a satisfactory Criminal Records Bureau and Protection of Vulnerable Adults list checks, two written references and all other documentation and information listed in schedule 2 for all staff members prior to them commencing work in the home. Timescale for action 06/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP4 Good Practice Recommendations The Registered Provider should ensure that staff members receive training in the correct use of wheelchairs in order that service users remain comfortable and safe when using a wheelchair. Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 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 Devonshire, The DS0000013384.V270948.R01.S.doc Version 5.0 Page 24 - 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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