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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

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

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

The provider did not have an effective system in place to regularly to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

Prior to our visit, the home had recently had a change of registered manager. The previous manager left in October 2013 and the new manager was appointed shortly afterward.

At our last visit in May 2013, we saw that the provider had recently purchased and implemented a system that was designed to monitor the quality of the service provided. At our last visit we saw evidence that the system's quality monitoring programme had commenced. At this visit however we found that the system had not been implemented consistently since August 2013. The manager told us that they were unable to find evidence that any previous audits had been consistently undertaken and that it was it was “like starting from scratch” when they came into post. At this visit, we saw that the new manager had re-commenced a number of the audits but that they were not yet fully established or used to effectively identify and monitor the health and safety risks posed to people who lived at the home.

The three care records we looked at during our visit contained gaps in risk assessment and care plan information. We asked the manager how they ensured staff had access to clear, consistent information about people's needs and care. The manager told us a care plan audit was commenced in March 2014 but that this was the first audit they had undertaken. On the day of visit the care plan audit was not fully completed. Records showed the last care plan audit undertaken was in August 2013. This meant that the quality of assessment and care plan information had not been properly monitored by the provider to ensure the quality of care provided to people.

We asked the manager how accident/incidents information was analysed to identify any trends for example in the type of falls or location so that the home could learn from accidents/incidents and take appropriate action. The manager told us they had commenced monthly accident/incident audits in November 2013 shortly after they had come into post. We saw that the audits analysed the number and type of accidents/incidents but did not analyse trends or people with a high number of falls in order to inform care. This meant no learning from accidents or incidents was utilised to prevent similar incidents happening in the future. The manager could not find any evidence that any accident/incident audits had previously been undertaken.

The manager showed us a quarterly health and safety audit they had introduced in January 2014. We saw that it mainly focused on the control of hazardous substances (COSHH) in relation to staff use and the use of hoists. We were also shown evidence that a monthly infection control audit was introduced with three audits completed to date. The audits monitored the cleanliness of communal areas and the state of repair of some items of equipment such as wardrobes, chairs. Neither audit however assessed the risks posed to people who lived at the home in relation to their living environment. Records showed the last health and safety audit undertaken was in August 2013. This meant the provider had no adequate systems in place to identify and manage the risks to people's health, safety and welfare.

We asked to see evidence of the audits in place to check that the administration of medication was safe and meeting people's needs. We were shown evidence that a medication audit was completed in February 2014. Prior to February 2014, we were shown medication audits dated September 2012. We reviewed February audit and saw that where issues had been identified, appropriate action had been taken. The manager told us the audit had identified issues with suitability of the current pharmacy and that the home was process of transferring over to a new supplier. They said they had decided to postpone the audits until the new supplier was in post. This meant that there were no effective systems in place to ensure people’s medication was managed safely.

The manager told us that monthly staff meet