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Archived: Devon House Inadequate

The provider of this service changed - see old profile

Reports


Inspection carried out on 15 April 2019

During a routine inspection

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 carried out on 8 May 2018

During a routine inspection

This inspection took place on 8 May 2018 and was unannounced. Devon House is registered to provide accommodation for up to 11 people who require nursing or personal care and treatment of disease, disorder or injury. There were eight people living at the service on the day of the inspection. People who lived there needed support due to acquired brain injuries or neuro-disabilities.

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The previous comprehensive inspection took place on 12 and 14 September 2017. At that inspection we found five breaches of regulations. These related to safe care and treatment, consent, safeguarding, notifications of significant issues to CQC and governance of the service. We carried out this comprehensive inspection to ensure the requirements of the regulations were now being met and that the provider had implemented their action plan.

The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe and were happy living at the service and that staff were kind and caring.

We found medicines were safely managed and risk assessment documentation was in place to provide guidance to staff in managing risks.

The service had appropriate documentation in place in relation to consent and compliance with the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The service had improved procedures and systems so people were safeguarded from abuse. When incidents occurred, they were dealt with appropriately and relevant organisations were notified including CQC.

Staff understood people’s needs and preferences and care records reflected these.

Person centred activities took place at the service and people told us they enjoyed them.

Recruitment of staff was safe. Staff told us they felt supported and regular supervision and appropriate training took place to support staff in their role.

People were supported to eat well, and were supported by the service and other health professionals to lead healthier lives.

The management of the service had changed since the last inspection and relatives praised the changes at the service since September 2017. Audits were taking place locally and at provider level, to ensure quality standards were checked and improved. These included medicines, care records and building safety. Complaints were dealt with promptly.

Inspection carried out on 12 September 2017

During a routine inspection

This inspection took place on 12 and 14 September 2017 and was unannounced.

The previous comprehensive inspection took place on 23 January 2017. At that inspection we found there were three breaches of regulations. These related to staff supervision, lack of person centred care in relation to activities and governance of the service. We served a Warning Notice on the provider in relation to governance of the service.

We carried out this comprehensive inspection to follow up on the Warning Notice and ensure the requirements of the regulations were now being met.

Supervisions were now taking place at the service and activities had improved to some extent. However, there remained a breach in relation to the governance of the service. In addition we found breaches of regulations in relation to risk assessments, safe management of medicines, safeguarding service users from abuse and improper treatment and the need for consent. We also found one incident which should have been notified to the Care Quality Commission and had not been notified. This was a breach of the regulations.

Devon House provides accommodation, nursing care and support with personal care for up to 11 people. At the time of our visit, nine people lived at the home who needed support due to acquired brain injuries or neuro-disabilities.

The home had a registered manager in place during our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found medicines were not being managed safely. There were errors when reconciling stocks against medicines for boxed medicines and one controlled drug was stored on the premises when it should have been returned to the pharmacist or destroyed.

Although a number of risk assessments were in place and up to date, there were insufficient risk assessments for a person who had recently used the service twice for respite. We also noted two other risk assessments which were either inaccurate or contained information which was contradictory.

Although there was appropriate documentation in place to restrict some people’s liberty due to their vulnerability, two people were being monitored at night without the appropriate safeguards in place.

Accidents, incidents and behaviour logs were not always being reviewed by the registered manager with remedial action taken which meant people were not always safeguarded from abuse or harm. We were concerned there was an under-reporting of instances of behaviours that challenge.

The provider did not address adequately concerns around safeguarding or consent.

Group staff supervision was now taking place regularly and staff told us they received regular supervision which they found helpful. New staff undertook an induction, and all staff completed training in key areas.

At the last inspection people and their relatives told us activities were not regular and records did not detail if people were taking part in regular activities. At this inspection we found each person had an activity plan in place and their activities were usually recorded on their daily record. However, at the time of the inspection the service had not recruited to the post of activity co-ordinator, although an advert had been placed. Some trips out had been organised in recent months, and people went for a coffee or the shops locally. At the time of the inspection people continued to spend a lot of time at the service carrying out activities on site.

At the last inspection we found one person’s Percutaneous Endoscopic Gastrostomy (PEG) tube feeding schedule was not easily accessible to staff. Fluid balance charts for people with PEG tubes did not have 24-hour totals to reflect the overall intake

Inspection carried out on 23 January 2017

During a routine inspection

This inspection took place on 23 January 2017 and was unannounced. The previous inspection took place on 16 March 2016. At that inspection we found the home was in breach of six legal requirements and regulation associated with the Health and Social Care Act 2008. We found that risk assessments were not in place to protect people and medicines were not being managed safely. Mental capacity assessment had not been carried out in accordance to the Mental Capacity Act 2005 (MCA). Some people’s food was not being monitored and actions plans were not in place for people at risk of losing weight. People were not involved in activities that would provide social and therapeutic stimulation. Regular audits were not being carried out to identify shortfalls and make continuous improvements and people’s and staff feedbacks were not being obtained through surveys.

We served a warning notice following the inspection as medicines were not being managed safely. We carried out a focused inspection on 6 September 2016 and found improvements had been made and medicines were being managed safely.

Devon House provides accommodation, nursing care and support with personal care for up to 11 people. At the time of our visit, 10 people lived at the home who needed support due to acquired brain injuries or neuro-disabilities.

The home had a registered manager in place during our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The home had a manager in place and the provider told us that the manager will be applying for registration.

Medicines were being managed safely.

There was an activities timetable for each person and we observed people took part in activities. However, people and relatives told us that activities were not regular and records did not detail if people were taking part in regular activities.

The feeding plan for one person who received nutrition via a PEG (Percutaneous Endoscopic Gastrostomy) tube was not easily accessible to staff. Fluid balance charts for people with PEG tubes did not have 24-hour totals to reflect the overall intake and to make sure the input feeding plans were being followed accurately and the people were hydrated.

Staff told us that they felt supported, but regular supervisions were not always carried out. There were limited records to demonstrate when supervisions had been carried out.

There were concerns with record keeping as we found that daily records were not being completed in full to accurately describe people’s activities, the registered manager was unable to locate one person daily notes covering nine days and staff supervisions that had been held in November 2016.

Risks were being identified and preventative measures put in place to prevent the risk of health complications.

The home had adequate staffing levels. We observed that staff were prompt in supporting people and people were supervised at all times.

Improvements had been made in assessing people’s capacity to make decisions in a particular area. MCA assessments had been carried out, assessing people’s ability to make decisions. Most staff we spoke to were able to tell us about the principles of the MCA and how the test was applied to determine if a person had capacity to make a specific decision about their care.

DoLS applications had been made to deprive people of their liberty lawfully in order to ensure people’s safety.

Food intake was being monitored for people with specific health concerns and appropriate intervention had been made to ensure people were at best of health.

Staff working at the home had received training they needed to do their jobs effectively. Staff had received induction when starting employment.

Inspection carried out on 6 September 2016

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 16 March 2016 and six breaches of regulations were found relating to consent, risk management, nutrition and hydration, person centred care and good governance. In addition, the provider was not providing care in a safe way as they were not doing all that was reasonably practicable to ensure the safe management of medicines. Following the inspection we served a warning notice on the provider and registered manager requiring them to comply with the regulations for the safe management of medicines.

We undertook this unannounced focused inspection on 6 September 2016 to check that the provider had met the requirements of the warning notice. At this inspection we looked at aspects of the key question 'Is the service safe?’ This report only covers our findings in relation to the focused inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Devon House’' on our website at www.cqc.org.uk.

Devon House provides accommodation, nursing care and support with personal care for up to 11 people. At the time of our visit, 11 people lived there who needed support due to acquired brain injuries or neuro disabilities.

The home had a registered manager, who was on leave during the inspection. Staff assisted us with the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

During our focused inspection we found the provider had made considerable improvements with medicines. Medicines were stored and managed safely. Staff had been recently trained and new protocols were in place. Regular audits were being completed to ensure the management of medicines was safe and follow up action was recorded.

The home had met the requirements and regulations identified in the warning notice, although we need to see consistent improvements over time before we are able to change the rating of this service from Requires Improvement.

Inspection carried out on 16 March 2016

During a routine inspection

This inspection took place on 16 March 2016 and was unannounced. Our inspection of 13 and 14 May 2015 found that people who lived at the home were not always supervised adequately by staff and there was a need to review staffing arrangements. We also found the home lacked a varied activities programme to provide social and therapeutic stimulation.

Devon House provides accommodation, nursing care and support with personal care for up to 11 people. At the time of our visit, 11 people lived there who needed support due to acquired brain injuries or neuro-disabilities.

The home had a registered manager, who was on leave during the inspection. A manager from another service assisted us with the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

Medicines were not managed safely. The provider did not have arrangements in place for the proper and safe management of medicines.

People were not always protected from risks associated with their support, as some risk assessments were not updated to reflect the person’s current needs or did not consider their specific health needs. Some risk assessments did not provide clear guidance to staff on how to mitigate risks relating to skin breakdown and challenging behaviours

Staff supervision was not consistent and regular one to one meetings were not being carried out. Some staff had not received annual appraisals.

People were given choices during meal times and their needs and preferences were taken into account. Nutritional assessments were in place for most people, which included the type of food they liked and disliked. We found food was not being monitored for some people with specific health concerns to ensure they had a healthy balanced diet. People’s weight was monitored. However, we did not see an action plan to indicate what staff should do if people lost weight or gained weight drastically.

People’s rights to make decisions about their care and support were not protected. Staff had limited understanding of the Mental Capacity Act 2005 MCA and Deprivation of Liberty Safeguards (DoLS) despite undertaking an e-learning programme. Five people were being unlawfully deprived of their liberty as they were not free to leave the service premises and the provider had not sought appropriate DoLS authorisations on their behalf. Additionally, we found that people’s capacity to make decisions about their care and support had not been assessed by the provider in accordance to the MCA principles, and best interest decisions made on their behalf, particularly relating to support with finances.

People were not involved in activities that would provide social and therapeutic stimulation.

Regular audits were not being carried out to identify shortfalls and make continuous improvements. We did not see documentary evidence that audits were being carried out on people’s and staff records such as care plans, risk assessments and supervision that would have helped identified the issues we found during the inspection.

We did not see evidence of quality monitoring systems in place such as surveys and questionnaires to allow people and their relatives to provide feedback on the service and if improvements were required.

People told us they felt safe. Staff were trained in safeguarding adults and knew how to keep people safe. They knew how to recognise abuse and who to report to and understood how to whistle blow. Whistleblowing is when someone who works for an employer raises a concern which harms, or creates a risk of harm, to people who use the service.

Recruitment and selection procedures were in place. Checks had been undertaken to ensure staff were suitable for the role.

People were referre

Inspection carried out on 13 and 14 May 2015

During a routine inspection

We undertook this unannounced inspection on 13 and 14 May 2015 of Devon House to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Devon House is newly registered to provide nursing care, treatment of disease, disorder or injury and accommodation for a maximum of eleven adults. People admitted to the home may have an acquired head injury or a neuro-disability. The home previously provided only personal care and accommodation. It’s registration was varied to include Nursing Care and Treatment of Disease, Disorder or Injury in December 2014. At this inspection there were eight people living in the home. The provider met all the standards we inspected against at our last inspection on 24 July 2014.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act and associated Regulations about how the service is run. The registered manager recently transferred to another home run by the company and the current manager had applied for registration.

People informed us that staff were respectful and their care needs had been attended to. They told us that they felt safe in the home. There were suitable arrangements in place for protecting people from abuse. Staff had received training and knew how to recognise and report any concerns or allegation of abuse. We observed that staff interacted well with people and spoke to them in a pleasant manner. When people wanted to talk with staff, staff were attentive and spent time with them.

There were suitable arrangements for the recording of medicines received, storage, administration and disposal of medicines. People informed us that they had been given their medicines. Infection control measures were in place. The arrangements for the provision of meals were satisfactory and people were provided with enough to eat and drink.

Staff had been carefully recruited and provided with appropriate training. Regular supervision and support had been provided to enable them to care effectively for people. Feedback received from people and staff indicated that there were occasions when people were not adequately supervised and they stated that at times there was insufficient staff. We noted that on the morning of our first visit people were inadequately supervised. We have made a recommendation regarding this. The manager responded promptly and ensured that staff were present in the lounge when people were there.

People had been carefully assessed and their choices and preferences had been noted. Risk assessments and care plans had been prepared. There was evidence that the healthcare needs of people had been attended to. Reviews of care had been carried out where the care and services provided had been discussed with people and their representatives. The service did not have a varied activities programme to provide adequate social and therapeutic stimulation for people. We have made a recommendation in this area.

The majority of staff had received training in the Mental Capacity Act 2005 and were knowledgeable regarding action to take if people could not make decisions for themselves because of their mental condition. The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS ensure that an individual being deprived of their liberty is monitored and the reasons why they are being restricted is regularly reviewed to make sure it is still in the person’s best interests. DoLS applications had been submitted as some people required continuous supervision for their own safety.

There were arrangements for ensuring that complaints made had been promptly responded to and the complaints record was also regularly checked by the regional manager. The home had arrangements for quality assurance. This included audits and checks on medicines, health and safety and care documentation by nursing staff and senior staff of the company. Two professionals who provided us with feedback stated that they were satisfied with the quality of care provided.

A third social care professional who spoke with us informed us that they found deficiencies in the management of the home when they visited recently. The regional manager indicated that the service provided was newly registered and they welcomed feedback so that the service could be improved and where deficiencies were noted they would seek to rectify them.

Inspection carried out on 24 July 2014

During a routine inspection

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions: is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with seven people who used the service and three staff. We also reviewed records relating to the management of the home which included the care records of three people who used the service.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found there were procedures in place to protect people from abuse. People who used the service had various mental health conditions which may have affected their comments about the service however most people we spoke with gave us positive feedback and said they felt safe and secure at Devon House.

We also found there were enough qualified, skilled and experienced staff employed to meet people’s needs.

We saw people’s care plans took into account the person's level of independence and any potential or actual risks to their safety or welfare. A range of risk assessments were in place, which included the actions staff needed to take to minimise or control such risks.

The service had an emergency plan which contained action plans for the different type of emergencies and every person who used the service had personal emergency evacuation plans in place. Staff training records showed they completed crisis management, emergency procedures awareness, and fire safety e-learning courses.

At the time of our inspection people at the home were not subject to the Deprivation of Liberty Safeguards (DoLS). The deputy manager at the home was aware of their responsibilities within the framework of the DoLS and that an application to the local authority had to be made if a person’s liberty for any reasons needed to be restricted.

Is the service effective?

People’s needs were assessed and care was planned and delivered in line with their individual care plan. We looked at three person’s care records during our inspection and saw they contained information about the person, a brief life history, their individual care and support plans. We found the care plans were person-centred and provided information to staff to enable them to provide personalised care.

We saw people’s weight was monitored on a monthly basis and they were supported to receive medical check-ups which included visiting their GP, dentist and optician. We also found when there were concerns about a person’s well-being or mental health the person was supported to receive specialist attention.

Is the service caring?

People told us “I’m settled now, that’s very important”, “I’m happy here” and that Devon House was a “very good place.” People said and we observed during our inspection that people were treated kindly and with respect. People also said “they (staff) are very nice” and “I’m happy with the staff.”

People's diversity, values and human rights were respected. We observed the care that was provided during our inspection and saw people were treated as individuals with patience and respect. People had their own room and we saw their privacy was respected by knocking on the door and not entering the room if permission wasn’t given. We saw people’s care record were person centred and took into account their individuality and their cultural or religious needs.

Staff supported and involved people in planning and making decisions about their care and support through monthly one to one meetings and regular meetings. The records of the meetings showed every person was asked about what was important to them with regards to their support and future plans.

Is the service responsive?

People had access to activities that were important and relevant to them and were protected from social isolation. They were able to decide how to spend their time and they were encouraged to improve their life skills. We found their autonomy and independence was promoted by enabling them to prepare their own meals, do household tasks and by encouraging people to do as much as they could for themselves.

We found the views of people who use the service were regularly sought through daily conversations, key-working sessions and service user meetings. The records of the service user meetings showed they were asked about what was important to them and discussed issues regarding their activities and the menu. We found changes to the service had been made following their feedback, for example changing the menu or replacing the TV in the communal lounge.

Is the service well-led?

Devon House had a system in place to monitor the quality of its service through internal audits and checks on different aspects of the service. The provider’s area manager audited the home every other month to check if the quality of the service was satisfactory, the records were kept up to date and people who used the service were satisfied with the care and support they received. Records showed recommendations were made and implemented. There were procedures in place to carry out various health and safety checks to ensure people were getting a safe service.

We found the views of people who use the service were regularly sought and were acted upon. There was also evidence that learning from incidents or investigations took place and appropriate changes were implemented.

Inspection carried out on 6 June 2013

During a routine inspection

During our inspection on 31 January 2013 we identified concerns regarding the implementation of one person's deprivation of liberty safeguard arrangements. We were also concerned that the service was not routinely recording and analysing incidents. Since then, the provider had made changes to address these concerns.

During this inspection there were 10 men living at the service. We observed that staff interaction was friendly and encouraging and people appeared comfortable with them. One person we spoke with said, "Staff do try and help." There was a detailed plan for reducing identified risks. Staff took time to explain care tasks to people in order to obtain their consent. Staff spent time with people who needed support to develop daily living skills. The service had developed good relationships and cooperated with external agencies and there were regular meetings with the mental health team to discuss the treatment and support needs of people using the service. Staff were supported by a training programme, regular meetings with line managers and group support sessions. The provider had effective systems in place to meaningfully monitor the quality of the service.

Inspection carried out on 31 January 2013

During a routine inspection

We spoke with three people who use the service. People were positive about the service and the care provided. Comments included, “I feel safe here and that’s important to me.” People were supported to prepare meals and the food provided was nutritious and in sufficient quantities. The registered manager had taken steps to ensure the premises were being maintained appropriately. Staff received appropriate training to work with people who use the service.

Care planning processes included consideration of people’s capacity to make decisions. However, we found concerns regarding how the service was implementing people’s care plans. We also found that the organisation was not always monitoring the quality of the service in line with its own procedures to make changes to treatment or care provided to people who use the service.