Devonshire House and Lodge

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

People felt safe and protected from the risk of harm and abuse. Systems were in place to keep people safe. There was a safeguarding policy, staff had safeguarding training and told us how they would report any concerns. Staff said they were confident all concerns would be dealt with appropriately. Staff supported people who had capacity to make decisions about risk. Risk assessments were completed to promote independence and minimise risks to people. Where people did not have capacity all necessary actions had been carried out under the Mental Capacity Act including making applications under the Deprivation of Liberty Safeguards (DoLS). Keypad locks were in place on all exits from each of the 4 units and these restrictions of peoples’ freedom to leave the home, had been managed appropriately to ensure that people who had capacity could leave freely as they wished. Care plans were clear, comprehensive and provided guidance to staff to keep people safe. The provider ensured there were sufficient, safely recruited staff on duty, who had received training to meet peoples’ needs. Leaders created and were embedding a positive and proactive learning culture at the service. Any incidents or accidents were reviewed and investigated by the manager and the management team. They reviewed individual accidents and incidents to check that all necessary action had been taken in response. They also monitored these records to identify any developing trends that might indicate further changes were needed. As a result of actions taken earlier in 2024 there had been a large reduction in the frequency of falls of those using the service. The action taken by the management of the service had helped to maximise people’s safety and enabled staff to deliver safe care and support.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were safeguarded from abuse and avoidable harm. Those we spoke with said they felt safe living at the service. Relatives who sent us their views of the service during the assessment all said people were safe. People and their relatives knew who to speak with if they had any concerns. They told us the manager and staff were approachable and would listen to any concerns. During the site visit we saw consistently kind and respectful interactions between people and staff.

People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. We heard from staff who told us about how they would protect people from potential abuse and how they were confident to speak up if they had any concerns about people’s safety or wellbeing.

Staff received safeguarding training to help them understand and identify possible signs of abuse and the appropriate action to take. The provider’s safeguarding policy gave clear guidance for staff about how to raise a safeguarding alert. When people had been assessed as lacking mental capacity to make a certain decision, staff clearly recorded assessments and any best interest decisions. Where needed, appropriate applications for legal authorisations had been made to restrict a person’s liberty.

Risks to people were managed to ensure they were safe. People were supported to be as independent as possible, with measures in place to reduce known risks. For example, one person told us about the care and specialist equipment they had to keep them safe and meet their needs. They were also protected from risk of deterioration through extensive and comprehensive monitoring, even though assessed by commissioners as not requiring nursing care. The service was delivering continuous assessment and support to this person through for example, the use of best practice assessment methods such as the (Rockwood) Clinical Frailty Scale tool.

Staff and managers kept people safe by regularly reviewing and updating people's risk assessments and their care plans to initially reflect their needs on admission, and any subsequent changes to their needs. The care plans were comprehensive and were also being used practically to guide and direct staff practice to ensure people’s risks, needs and preferences were met.

Staff were seen on hand to support people as necessary to manage their risks. For example, at least one staff member was present on ‘Moorland View 2’ unit’s communal lounge and dining area. This designated staff presence in communal areas, individual staff walking with people who were at high risk of falls, the introduction and use of new falls risk management equipment, in addition to frequent and comprehensive use of risk assessment had reduced the number of falls taking place in the service.

Peoples’ human rights were being respected. The service was working within the principles of the Mental Capacity Act 2005. We saw staff supported people to make as many of their own decisions as possible. Staff knew about people’s capacity to make decisions, and this was documented. Applications for Deprivation of Liberty safeguards (DoLs) had been made as appropriate for some of the people that used the service. We noted that there were keypad locks on all the exits from the 4 units within the home. These keypads were required to keep people without capacity safe. People with capacity had been given the keypad codes, as well as some peoples’ relatives, so that they could move around and leave the building unrestricted.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives told us that the staffing at the home had improved considerably recently and commented on the qualities of the staff. One person said “they (the staff) are all really good. They are very kind”

The provider used a dependency assessment tool, to carry out continuous assessment of the needs of the people using the service. The outcomes of this assessment were used to identify the necessary number and skills, of the staff required to meet peoples’ needs. There had been a recent introduction of an increased staffing level, and the recruitment of 14 new staff including nurses since Feb 2024. During this assessment staff said they now felt the staffing was appropriate, and the new staff would be well skilled when they had fully completed their training. Staff and managers told us the training being provided had improved considerably recently and they particularly benefitted from more of the training being delivered in person. Staff spoke positively about the training programme they were receiving.

We saw happy interactions between staff and people, as well as between staff. The introduction of an additional day and night staff member onto the original rostered number of staff, had greatly improved people’s quality of life and had proven highly successful in reducing the number of falls experienced by people using the service. We saw the skill with which staff supported people, the excellent way in which the activities coordinator and staff were delivering the new activities programme, and the positive approach shown by staff.

Files relating to the safe recruitment of staff were complete and contained records of all necessary checks including Nursing registration PIN records, and right to work visas for overseas staff. The provider was ensuring that their recruitment procedures were carried out thoroughly ensuring that staff were safe to work with people who used the service. We saw records showing that staff were not only receiving their basic mandatory training but also more specialist training to increase the knowledge and abilities of already experienced staff. Supervision records showed that staff were receiving regular individual support and staff said that they were being well supported by their managers.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.