Devonshire House and Lodge

Devonshire House and Lodge is a care home that provides personal and nursing care to 77 people aged 65 and over. At the time of the inspection 76 people were living at the service.The service mainly provides care and support to people living with dementia and/or have a physical or sensory impairment.

We found the following examples of good practice.

There were suitable arrangements in place for visitors to the care home. These included, pre-booked visits, temperature checks lateral flow tests (LFT) and availability of personal protective equipment (PPE).

Indoor visits were mainly accommodated in one of the homes a conservatories. There were outside areas available and these had been used when the weather was good. The provider ensured current guidance relating to visiting was followed. This included; nominated visitors, visits for end of life care and essential visitors to support exceptional care needs. In addition to visits the service used social media and telephone calls to enable people to maintain important contacts.

The registered manager kept people and relatives regularly updated in relation to visiting guidance. This included sending updates of the guidance and home’s visiting policy as well as communicating with relatives regularly by phone and email. A booking system was in place, which was regularly audited to ensure visiting was safe and fair.

At the time of the inspection Government guidance in relation to care home visits had just changed. These changes included an increase of two nominated visitors to five. The registered manager was in the process of sending updates to relatives and reviewing the homes visiting arrangements to reflect this change and to ensure visits could take place safely and in line with guidance.

People and staff had regular COVID-19 tests in line with guidance. The care home had not had any outbreaks of COVID-19. The layout of the building and separate units was suitable for implementing zoning if needed and the providers COVID-19 contingency plan was reflective of this.

Staff only worked in one home and the use of agency staff was kept to a minimum. If agency staff were required, they used consistent staff who participated in regular testing provided by the agency they worked for. Risk assessments were carried out for ‘high risk’ staff members.

Personal Protective Equipment (PPE) and hand-washing facilities including hand sanitizer was readily available around the home. Staff wore PPE in line with guidance and had undertaken infection control training. Areas were set aside for putting on and taking off PPE, and there were clear systems for disposing of waste safely.

The premises were visibly clean and hygienic. A cleaning schedule was in place with enhanced cleaning of regularly touched surfaces, such as door handles and light switches. Regular cleaning audits were completed.

The registered manager was kept regularly updated on guidance. They had access to support from the provider, Public Health England and other homes managers within the organisation.

Devonshire House and Lodge is a care home that provides personal and nursing care to 71 people aged 65 and over. The service mainly provides care and support to people living with dementia and /or have a physical or sensory impairment.

There were suitable arrangements in place for visitors to the care home. These included lateral flow tests (LFT), personal protected equipment (PPE) being available at the entrance and pre-booked visits. Temperature checks on visitors were carried out and recorded.

Visits were accommodated in a conservatory, whereby there were protective clear screens. There were outside areas which could also be used when the weather was good. The care home ensured that current guidance relating to visiting and having nominated visitors was followed, this also included for end of life care and visits in exceptional circumstances. The care home used social media and equipment to enable residents to maintain contact with family and friends.

Devonshire House and Lodge had tried social distancing for residents, but this had affected their mental wellbeing, so residents socialised together in their preferred groups. PPE was readily available around the home and staff and people had regular COVID-19 tests in line with guidance. A total of 68% of people living at the service had received both vaccines.

Current guidance on safe admissions to the care home was being followed. Information was gathered from hospital and if possible, from other relevant people.

The care home had not had any outbreaks of COVID-19, but the premises were suitable for implementing zoning if needed and the providers COVID-19 contingency plan was reflective of this..

Areas were set aside for putting on and taking off PPE. Clinical waste processes were effective, with clear signage on how to dispose of waste safely.

Staff had completed infection control training, which included specific COVID-19 modules. Regular audits were carried out for infection control, which included premises and hand hygiene audits, with action taken if needed.

The premises were visibly clean and hygienic and cleaning was carried out regularly, with enhanced cleaning on touchpoints, such as light switches and door handles.

The registered manager was able to access support from the provider, Public Health, and other care home manager's in the group of homes which Devonshire House and Lodge was part of. Staff only worked in one home and when needed, agency staff were block booked into shifts and participated in regular testing provided by the agency they work for. Risk assessments were carried out for 'high risk' staff members.

Since the inspection the guidance around visiting had changed, therefore we contacted the provider who confirmed they had changed the visiting arrangements in line with the new guidance. This meant people could have two designated visitors inside the service, as well as window visitors.

People’s experience of using this service:

• People were valued as individuals and treated with care and compassion. Staff emphasised how important it was to know each person well in order to provide person centred care. This deep knowledge of people also helped staff understand when people needed reassurance and how best to provide it. People, family members and professionals gave consistently positive feedback about the caring culture of the home. Comments included, “I am so blown away by the staff” and “The staff are more like friends and family.”

• Staff engaged positively with people throughout the day. This helped build strong bonds that increased people’s confidence in sharing their views about their care and the service. Staff knew how to communicate with people so people understood the options available to them. Staff were skilled in understanding people’s responses.

• The registered manager and staff extended their care and compassion to people’s family members and saw them as part of the home’s community. Comments included, “[…] is getting the most gentle, loving care and so are we!”

• People, relatives, staff and professionals gave exceptional feedback about the impact the registered manager had had on the home and on the lives of the people living in it. Staff told us they saw the registered manager as a role model. It was clear staff had adopted the registered manager’s approach to the care of the people living in the service. People were encouraged to share things staff had done that mattered to them and staff were rewarded for their contribution.

• The registered manager had a clear vision for the service and took regular action to help ensure this vision was realised. This included engaging the local community in the life of the home and supporting people to be a part of their local community. They told us, “This is a home and people in it should be a part of their community. It’s about people being included and valued.”

• People lived in a service that kept them safe. Staff had been recruited safely and had received training on how to recognise and report abuse. People were supported to take their medicines safely and to reduce any risks relating to their individual health and care needs.

• People’s care was provided in line with best practice. People were cared for by staff who received regular training that was tailored to meet the needs of the people living in the service.

• People’s needs and preferences regarding food and drink were known and respected. People told us they liked the food and staff gave examples of things they did to help ensure people got the food they liked, whilst maintain their health.

• People’s ideas and preferences were sought and listened to in relation to the internal and external environment. People were offered a variety of different ways to spend their time. Staff understood what people enjoyed doing and constantly worked to offer a variety of activities based on people’s preferred pastimes and hobbies.

• We have made a recommendation about the management of some medicines.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: Requires Improvement (report published 12 April 2018). We did not request an action plan as there were no regulatory breaches.

Why we inspected: This was a planned inspection based on previous rating.

Follow up: We will continue to monitor the service through the information we receive until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Devonshire House and Lodge accommodates up to 77 people across four separate units, each of which has separate facilities. The units include nursing care, residential care and dementia care. At the time of the inspection 46 people were living in the service.

This inspection took place on 8, 9 and 11 January 2018 and was unannounced.

We had carried out an unannounced comprehensive inspection on 20 and 21 April 2017. The overall rating was inadequate, therefore the service entered 'special measures'. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

We told the provider to make improvements to how people's medicines were managed, how people were protected from risks including the spread of infections and in the event of an emergency evacuation, how staff were deployed and how incidents were recorded and managed. We also told them to ensure people were treated with dignity, to improve records of people's individual needs, to ensure confidential information was protected, to ensure there was enough for people to do and that the Mental Capacity Act 2005 (MCA) was followed. We also told them to improve their systems to monitor the quality of care people received, to inform the commission of significant events and to ensure advice from external agencies was acted upon.

The Commission considered its enforcement policy, and took enforcement action which was to impose a condition on the provider's registration. This meant the provider was required to carry out audits of the service, describe what action was being taken to improve the service and to meet the regulations; and submit a report of their findings on a monthly basis to the commission. The Commission then reviewed the provider's monthly returns to ensure improvements were being made. We also used the information in these reports to inform this inspection.

During this inspection the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures and no longer has to submit monthly reports; but some further improvements are still required.

People had risk assessments in place but these did not always reflect the full range of risks people might experience due to their individual health or social care needs. Staff had a good understanding of the Mental Capacity Act, however people’s records did not always clearly reflect whether someone had capacity or not, or show how their legal rights were then protected.

Staff had an in depth knowledge of people’s needs however, people’s care plans did not always contain this level of detail about their routines and preferences. Monitoring of the quality of the service had improved. The provider, manager and staff regularly undertook a range of audits and spoke with people to ensure they were happy with the service they received. However these had not identified the areas for improvement highlighted during this inspection.

A new registered manager had been employed to manage the service. 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been employed following the last inspection and had been in post for seven months at the time of this inspection.

Since the last inspection, the governance systems in the service had been reviewed. This had resulted in improved systems, procedures and audits, which staff understood and were involved in. The registered manager was still developing these to ensure the service continued to improve. They had notified the commission of all significant events, as required.

There was now a positive culture within the service. The registered manager led by example and staff told us they felt happy and supported in their work. People, their relatives and staff told us they had noticed the improvements that had been made since the registered manager had been in post. They also confirmed the management team were approachable and included them in discussions about individual’s care and the running of the service.

People’s dignity and confidentiality were now understood and respected by staff; and people were treated with kindness and compassion. People now had more opportunity to remain physically and cognitively stimulated and the registered manager ensured people were consulted about what opportunities were available to them.

People and their relatives spoke highly of the staff and the support provided; and confirmed staff now responded to any requests promptly. There were sufficient numbers of suitably qualified staff to meet the needs of people who used the service and the registered manager ensured these were deployed effectively across each unit. The recruitment process of new staff was robust and the provider was in the process of checking previous recruitment files.

Staff used their knowledge of people to help ensure their diverse needs were met and were prompt in responding to people’s requests. People told us they enjoyed the food and there were now procedures in place to ensure people received the support they needed at mealtimes. Staff were aware of how much people should eat and drink to remain healthy and reported any concerns they had. When people were identified as at risk of weight loss, prompt action was now taken, for example they were referred to their GP. Information and advice from external professionals was now recorded and acted upon.

People told us they felt safe living at Devonshire House and Lodge. Staff had received training in how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected. People now received their medicines safely and as prescribed.

Records had now been put in place to ensure people would be protected in the event of an emergency evacuation; and systems implemented to help ensure this information remained up to date. Staff understood how to protect people from the risk of cross infection and ensured incidents were recorded effectively and acted upon. People reported that any concerns they had were now taken seriously by staff and action was taken.

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.

The inspection took place on 20 and 21 April 2017 and was unannounced.

Devonshire House and Lodge is a purpose built nursing home providing residential and nursing care for up to 77 people. Devonshire House and Lodge is part of the corporate group Harbour Healthcare. The home is divided into five units, two nursing units and three residential units. On the days of the inspection 52 people were living at the home. Devonshire House and Lodge provides care for older people who may also have mental health needs which includes people living with dementia.

A manager was employed to manage the service who was in the process of registering with Care Quality Commission. 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The manager had only been employed for three weeks and was in the process of getting to know the service.

Prior to our inspection we received information of concern that there were insufficient staff and equipment to meet people’s needs safely. Concerns were also raised that people’s dignity was not always respected by staff, there were no emergency evacuation plans for people, medicines management and administration was unsafe and people’s records were often unclear and completed inconsistently.

Following the inspection, we received further concerns from health and social care professionals about the safety of people living at Devonshire House and Lodge.

At our last inspection on 2 and 3 November 2016, we found breaches of regulation. People’s care plans were not always easy to understand and were not reviewed regularly. Risks to people’s health and safety were not always assessed and actions identified to mitigate risks were not always followed. Records to monitor people’s health needs or concerns were not always completed correctly and people’s care plans did not contain clear information for staff about how to protect people’s rights, if they were assessed as lacking capacity. Staff were not always deployed effectively and did not always have competence, skills and experience to provide safe care and treatment. Equipment used by the service provider was not always assessed as being safe for their individual’s needs and people’s personal emergency evacuation plans (PEEPs) were not always clear. Audits were in place but these had not always been completed accurately or action taken as a result. Following the inspection they sent us an action plan which said they would meet all these requirements by 28 February 2017. At this inspection we checked whether improvements had been made.

During the inspection, we were informed the police were undertaking an investigation into unexplained bruising sustained by one person. Explanations for the bruising had not been recorded. This is also being investigated under the local authority safeguarding procedures.

We found staff were not always deployed effectively to keep people safe and meet their needs. We observed people who were calling for help receive no response from staff. People told us staff did not always respond to call bells or concerns promptly. People told us there was not always enough to do to occupy their minds and to keep them entertained. Comments included, “It’s boring living here, nothing to do is there?” and “There’s nothing to do much.” People’s care plans did not always give clear information about people’s preferences or how they wanted their needs to be met.

People were not always protected from risks associated with their care because risk assessments were not always in place; or did not provide clear guidance and direction to staff about how to keep people safe. When guidance was available, this was not always followed by staff. Incidents were not always recorded effectively which meant learning to reduce the risk of future incidents could be lost.

People were at risk of the spread of infection because staff had not all received training on infection control. People’s risk assessments and care plans did not contain clear information for staff to follow and appropriate protective clothing was not always readily available. People’s needs were not all recorded on a personal evacuation plan to be used in the event of an emergency.

People’s medicines were not always managed and administered safely. Staff had not ensured there were always sufficient medicines available for people and that medicines administration records (MARs), were completed accurately. People’s changing healthcare needs were not always recorded accurately, identified or acted upon. The provider had not ensured information and recommendations from external professionals had been embedded in practice. Staff were not always available to provide the support people required when eating and drinking. When people had not had enough to drink, records did not always show what action had been taken.

Some staff members understood how the Mental Capacity Act 2005 (MCA) applied to their role but records did not always give clear information about why someone had been assessed as lacking the capacity to make a certain decision. This meant their human rights may not always have been supported or respected. People’s dignity and confidentiality was not always protected and staff did not always show respect for the environment people lived in. The vision and values of the provider were not always reflected in the way staff worked.

It was not always clear who had responsibility for monitoring different aspects of the service and maintaining quality. The provider did not effectively follow systems and processes in place to help monitor the quality of care people received or act upon the results. When quality monitoring activities had identified gaps in the quality of the service, these had not always been acted upon. People’s concerns and complaints had not always been reported, recorded or acted upon. For example people and relatives told us they had reported to staff when personal items or clothing had gone missing but action had not always been taken.

People told us they enjoyed the food and said that staff were kind. Comments included, “The food is lovely and the chef is fantastic” and “The food is good, I mean really good.” Staff told us they enjoyed providing care and knew people well.

New staff received a thorough induction. Staff had received training and the manager was reviewing all staff training to help ensure all staff training was adequate and up to date.

People told us they felt safe using the service and that staff protected their privacy. Comments included, “I feel safe here because I like the staff.” Staff confirmed they knew how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected.

People had sufficient equipment and aids to meet their individual needs.

Staff told us they had confidence in the new manager and felt able to raise any ideas or concerns.

We asked the provider to respond to the immediate concerns we had about people’s safety at Devonshire House and Lodge. They sent us a plan detailing what action they would take to ensure people were safe. This included not admitting anyone to the service until they were confident the service was safely meeting people’s needs. This plan will be kept under review.

We found six breaches of the regulations. We are taking further action against this provider and will report on this when it is completed. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded. You can see what action we told the provider to take for two of the breaches at the back of the full version of the report.

A manager was employed to manage the service. They were in the process of registering with Care Quality Commission. 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the start of the inspection, the manager had been in post for two days. They were supported by a deputy manager who was also new to post, as well as nurses and/or senior carers who were responsible for the day to day running of each unit.

The inspection was prompted in part by notification of an incident following which a service user sustained an injury. The information shared with the CQC about the incident indicated potential concerns about the management of risk of falls relating to new flooring that had been fitted. Incident records showed that only one person had slipped on the new flooring and that the fall had been due to a spilt drink. We identified during the inspection that spillages were not always cleared away as soon as possible. The provider told us they would work with the staff team to improve their practice in this area.

Risk assessments to guide staff how to help mitigate risks relating to people’s care were not always up to date, reflective of people’s needs or followed by staff. Records to guide staff how to keep people safe if there was an emergency such as a fire were not always clear and during a fire alarm, some staff were not clear what actions to take. The manager and provider were in the process of reviewing everyone’s risk assessments and monitoring whether staff followed them. They also told us they would also ensure they clarified the guidance for staff regarding how to keep people safe in an emergency.

People who needed hoists to help them move did not have slings (which are used on the hoist) which had been assessed for their individual needs. This put people at a risk of injury or cross contamination from other people. The provider told us they would immediately order individual slings for people, according to their assessed needs.

People and staff told us there were sufficient numbers of suitably qualified staff to meet the needs of people who used the service. However, these were not always deployed in the most effective way to meet people’s needs. On the second day of inspection, this had resulted in two people still being in bed at midday. Staff told us this would not be the normal choice of the individuals. The manager and provider told us they had already made some changes to how staff were deployed and would have a closer overview of this in the future.

The manager and some staff had attended training on the Mental Capacity Act 2005 (MCA).

Staff had a basic knowledge of the MCA but when people lacked the capacity to make decisions for themselves, care plans did not always provide clear information for staff about how to ensure their rights were protected. The manager told us they would ensure staff received training and support to understand the MCA and review people’s care plans to include clear details for staff. Where people’s liberty was restricted in their best interests, the correct legal procedures had been followed. We have made a recommendation about the implementation of the MCA.

People were supported to see a range of health and social care professionals including social workers, chiropodists, district nurses and doctors. However, records to monitor people’s health were not always completed regularly or accurately. When people were at risk of skin damage, their pressure mattresses had not always been monitored to ensure they were at the correct setting for their needs. Staff also told us they were not aware of best practice regarding skin care for these people. The provider had already identified records were not being completed effectively and had put plans in place to improve recording in the future. The manager told us they would have a close overview of how records were being completed and would arrange training for staff regarding skin care.

The manager and provider had recently implemented actions to improve the safe management of medicines. However, fridge temperatures, recorded to help ensure medicines which required refrigeration remained effective, had not always been recorded. When people had been prescribed medicines to be taken ‘when required’, information was not always available to staff regarding when to administer the medicines. The manager told us they would have a closer overview of record keeping and work had begun, to improve people’s medicines care plans during the inspection.

Staff told us they had not always had the opportunity to read people’s care plans and that they were not always easy to understand. People’s care plans had not always been reviewed to reflect their up to date needs. Care plans were being transferred to the provider’s own system. The provider told us they had asked a senior staff member from a sister home to support the manager and staff to write personalised care plans for people. During the inspection, the manager spent time producing summaries of people’s likes, dislikes and care needs to give staff guidance when they were supporting people.

People told us they enjoyed the food. Mealtimes were a positive experience, which people told us they looked forward to. People told us meals were of sufficient quality and quantity and there were always alternatives on offer for them to choose from. People were involved in planning the menus and their feedback on the food was sought.

Some staff had received training in how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected. The manager told us they would prioritise refreshing staff knowledge of safeguarding. Recruitment practices were safe. Checks were carried out prior to staff commencing their employment to ensure they had the correct characteristics to work with vulnerable people.

People told us they felt well cared for. Comments included, “I can’t fault the care.” We observed staff talking in a kind, affectionate way with people and taking action to alleviate any anxiety.

The manager and provider had clear values about how they wished the service to be provided and these values were being shared with the whole staff team. Staff talked positively about the future of the service and told us the manager and provider were approachable and transparent. There was a complaints procedure in place and any complaints had been investigated and responded to within the timeframes set out in the policy.

A comprehensive range of audits were in place to monitor the quality of the service. However these had not always been completed thoroughly. This meant areas for improvement were not always identified or acted upon. Audits had also been carried out by the provider which had contributed to a service improvement plan. This was then used to prioritise areas of improvement and keep staff up to date with any changes being made. The provider told us, “People need a good quality and safe standard of care and we’re going to get it right.”

We found breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.