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Archived: Devon House Inadequate

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Inadequate

Updated 24 August 2019

About the service:

Devon House is a care home registered to provide accommodation, nursing and personal care for up to 11 people. The service supports people with an acquired brain injury, many of whom had complex physical health conditions. Some people also have additional mental health needs.

At the time of our inspection there were nine people living in the home, and one person was admitted for a short respite stay over the period of the inspection.

Why we inspected:

The inspection took place following notification of a serious incident in April 2019 in which a person using the service died.

People’s experience of using this service:

We found serious concerns regarding the governance of the service since the last inspection. The provider’s audits did not find all the areas of concern this inspection highlighted. We found even when the provider’s audits had identified areas of concern, action to make improvements had not always taken place, or been effective.

Whilst there were care plans in place for people, they lacked important detailed information regarding people’s health needs and how to meet them.

Risk assessments did not provide staff with detailed guidance to meet people’s needs safely in many areas including moving and handling, managing epilepsy and diabetes.

Staff were not provided with suitable support to carry out their role as there were low levels of supervision and lack of training in key areas. There was lack of consistent clinical leadership at the service as the provider had not adequately covered this role when a key member of staff was seconded to another service.

People who could communicate told us they liked living at the service and staff were kind and caring. People’s relatives and health and social care colleagues confirmed this was the case.

There were activities at the service which people enjoyed, and people spoke well of the food.

We saw residents’ meetings took place regularly so people’s views were considered in the running of the service.

Rating at this inspection and follow up:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

You can see what action we told the provider to take at the back of the full version of the report. However, full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been con

Inspection areas

Safe

Inadequate

Updated 24 August 2019

The service was not safe.

Details are in our Safe findings below.

Effective

Requires improvement

Updated 24 August 2019

The service was not always effective.

Details are in our Effective findings below.

Caring

Good

Updated 24 August 2019

The service was caring.

Details are in our Caring findings below.

Responsive

Requires improvement

Updated 24 August 2019

The service was not always responsive.

Details are in our Responsive findings below.

Well-led

Inadequate

Updated 24 August 2019

The service was not well-led.

Details are in our Well-led findings below.