Devonshire House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good.This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us what they would do if they had concerns about people’s health, welfare and safety. Incident forms were reviewed by the management team and learning documented and shared with staff. Relatives told us they were informed regarding any incidents and changes in the health and well being of their loved ones. However, the provider did not always have a proactive and positive culture of safety based on openness and honesty as covered in the well-led section of this report.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place to ensure people’s needs were assessed before they started using the service. The provider ensured there was an individual plan in place for people to ensure they had a smooth transition when they started using the service. People had care plans and risk assessments which were based on these assessed needs that were continually reviewed and updated when needed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People and their relatives told us the care was safe at Devonshire House. One person’s relative said,

“My [family member] has been here 18 months. I could not be happier with the care. They are magnificent the staff.” Another relative told us, “I feel [family member] is safe, I go very often to visit and I observe how the staff treat all people, not just my family member.” A third relative commented, “[Family member] is incredibly safe and the staff that look after them are great.”

Staff understood their responsibilities to report concerns and were trained about how to spot signs of abuse should they have occurred. Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of Liberty Safeguard (DoLS) was applied for through the relevant local authority.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had up to date risk assessments and associated care plans in place. This included where people were at risk of falls and weight loss. We raised that whilst action had been taken to make a healthcare referral relating to a choking incident, the person’s care plan hadn’t been updated. The covering manager took immediate action to address this.

There were snack stations situated around the home, where it was safe to do so, so people could help themselves to food and drinks between meals. We raised with the manager a lack of evidence of fortification of snacks where people were at risk of weight loss. They took action to follow this up.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The gardens around the home were not consistently well maintained. We observed this to be of a particular concern on Ryder Unit, where people living with dementia were cared for. There was no safe outdoor space that they could access. The garden furniture was in poor condition, with several pieces visibly rotten and unsafe for use. In addition, the paths around the gardens were uneven in places, creating potential trip hazards and limiting safe access for people, particularly those who required support with their mobility. These concerns meant the garden was not a safe or pleasant environment for people to enjoy. Following our inspection the provider told us progress had already been made and the garden areas were safe for people to access again.

Environmental risk assessments were in place such as fire safety, gas safety and water safety. These were up-to-date and where issues were identified, these had been addressed or there was a plan in place to address them. Environmental audits took place to monitor the safety of the premises and equipment. There was specialist equipment available to support people who needed this. People were provided with specialist beds, hoists, and other equipment to keep them safe. There were coded doors to help restrict access to non-communal areas to keep people safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together to provide safe care that met people’s individual needs. The majority of people and their relatives told us there were sufficient staff to meet people’s needs. One relative said, “There are staff everywhere. Occasionally they may be short but, on the whole, there are a lot of staff.” Another relative commented, “[Family member] wears a pendant around their neck. If [family member] presses it, they will rush to help.” Other relatives raised that there were shortages of staff at times. One relative said, “They don’t have enough staff on [Ryder]. The staff do the best they can but they are very stretched with the demand of [people].” Another relative told us, “The staff are very good to [family member], treat them like family but they are short staffedat times.”

We had mixed feedback from staff about the staffing levels with different examples of how this impacted care during the day and nigh. Staff told us how the individual circumstances and needs of people were not always considered in the staffing allocations. One staff said, “Suites have 12 people living there. We now have to watch [one person due to safety concerns] but we have another person who requires 2 staff to help them so we then have to take a carer from someone else in the home.” Another staff member told us, “I feel someone at Suites all night would keep people safer and happier as we need 2 staff on Main for the people who need 2 carers to help them.”

During the inspection we saw staff were visible in the home and they were very busy, however, they made time for people and their relatives, and their interactions were thoughtful and person centered. Staff told us that there were key times where the staffing levels were challenging, such as lunch time on Ryder, and that a whole home approach to support at these times was beneficial, however, did not consistently happen depending on the leadership at the time. The provider told us they would continue to review and closely monitor staffing levels and the deployment of staff across the service.

People were supported by staff who had been recruited safely. Pre-employment checks included obtaining references and checks with the Disclosure and Barring Service (DBS). The DBS helps employers make safer recruitment decisions and help prevent unsuitable people from working in care services. Staff told us they received the training required to undertake their roles safely.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff were provided with personal protective equipment (PPE) and were observed wearing and removing this appropriately. There were hand washing facilities throughout the building and also access to hand sanitising gel. We raised with the manager that a number of bedrooms had missing hand soap dispensers and immediate action was taken to address this.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Administration of medicines was recorded on an electronic system and at the time of the inspection was being witnessed by a second member of staff in line with an agreement with the local authority. All allergies and preferences for how people wanted their medicines administered were recorded. We observed staff administering medicines according to these preferences and treating people with care and dignity. However, due to technology problems within the system it was not always possible to accurately record the administration of the medicine on the system. This led to the electronic record being incorrect and managers reviewing after every medicine round to see whether medicines recorded as ‘missed’ had been truly omitted. This meant there was an increased risk of a medicines error occurring. The provider told us, after our inspection visits, that action was being taken to address the concerns with the system and alternative workarounds had been implemented.

Administration records for medicines such as to treat Parkinson’s disease, antibiotics and controlled drugs were not accurate. Medicines that were administered by a topical patch were not recorded on a body map to ensure the site of application was rotated appropriately. Administration records for topical medicines were not accurate and we were unable to tell which cream had been used and where it had been applied. The provider’s administration records did not reflect any medicines that had been given by the district nurse and were sometimes showing incorrectly on the electronic system. This made it difficult to track when medicines were due such as three-monthly vitamin injections.

Care plans were individualised and person centred but were not always up to date such as pain care pathways or end of life pathways. Protocols were in place to enable staff to know when to give ‘as required’ medicines.

Not everyone receiving covert medicines (medicines administered without their knowledge in their best interests) had all the correct information and authorisations in place to ensure the safe administration of their medicines.

All staff had their competency to administer medicines assessed. Medicines incidents were being reported and investigated. Currently there was intense scrutiny of medicines administration, and any discrepancy was fully investigated so we were assured that people were receiving their medicines as prescribed, but the medicines administration records did not fully reflect this