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Archived: Devonshire Manor

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Inspection report

Date of Inspection: 8 April 2014
Date of Publication: 10 May 2014

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 8 April 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff and talked with commissioners of services.

Our judgement

Care and support was not planned or delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

Some of the people who lived at the home had communication difficulties and were unable to speak to us. We spoke to two people who lived at the home and three relatives. They told us the care was good.

One person said “Staff do their best for us. Staff come when I need help and I’m very well treated” and relative comments included; “Care is good, staff go out of their way to help. They take their time, they are as good as gold” and “Staff talk to them. Staff know them well”.

We observed staff supporting people at lunchtime and throughout the day. We noted that there was a homely feel to the home and the people were relaxed and comfortable with staff. We saw that staff spoke to people with respect and treated people kindly. They supported people in a patient, warm manner and at the person’s own pace.

On the afternoon of our visit, the activities co-ordinator was interacting well with people at the home and encouraging their participation in a range of one to one activities. The manager was also in the process of planning an Easter party for people to participate in. This assured us people’s social and activity needs were met.

We looked at people’s daily written records which showed the care and support people had received. We saw that records monitored people’s general wellbeing. We spoke with two care staff. Staff were knowledgeable about people's needs and spoke fondly of the people they looked after.

We looked at the care records belonging to three people who lived at the home. We found assessment, care plan and risk assessment information was designed to outline each person's individual support needs. We saw that people's personal care requirements and preferences were documented and that some risks relating to the person's health and welfare were assessed for example malnutrition and pressure sores. Care records however did not adequately assess all of people's individual risks and lacked sufficient detail in some areas.

For example one person had been admitted to the home due to a recent fall. The person’s assessment was brief but indicated the person had risks associated with dementia, poor mobility, vision and a medical health condition. Risks however had not been assessed and planned for in the delivery of care. There was also no information on the impact of the person’s dementia on their decision making capacity or guidance for staff on how to communicate with the person.

One person’s GP records indicated that the person had been diagnosed with a mental health condition. There was no information in the person’s care plan and no risk assessment in place to identify how the condition impacted on the person’s day to day life or guidance to staff on how best to support the person. We asked the manager about this, who was not aware that the condition had been diagnosed.

Two people whose records we looked at had a history of falls and poor mobility but a review of their falls risk had not been undertaken since May 2013. We checked their accident/incident logs and saw that one person had had five falls since May 2013 and the other person had fallen twice since their last risk assessment. We found no evidence in people’s files that the home had taken appropriate action to keep the person safe for example, sought specialist advice from the falls prevention team. We asked the manager about this. They acknowledged that people’s risks had not been re-assessed after their falls or care plans adjusted. They also confirmed no referrals to the falls prevention team and no specialist advice had been sought. We asked the manager to seek specialist advice without delay and to inform us when this has been done.

There was also limited information in people's care records about their physical health needs identified at initial assessment. For example the signs and symptoms to spot in the event of ill health. This meant that there was no guidance to staff on how their conditions impacted on the care to