Archived: Devon House

Updated 24 August 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was prompted in part by notification of an incident in April 2019 following which a person using the service died. This incident is subject to investigation by other parties and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk in caring for people at the service. This inspection initially looked at Safe and Well-Led domains on 15 April 2019. However, we extended the scope to become a full comprehensive inspection, covering all five domains of the service to ensure we inspected all areas of care at the service. We visited the service on 23 April 2019 to complete the comprehensive inspection.

Inspection team:

The inspection team consisted of two adult social care inspectors, a specialist advisor nurse and one expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care home.

Service and service type:

The service provides care to people with an acquired brain injury, some of whom have mental health needs. The majority of whom are under 65.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection:

This inspection was unannounced on both days.

What we did:

Before the inspection, we reviewed information we held about the service, including previous reports and notifications sent to us at the Care Quality Commission. A notification is information about important events which the service is required to send us by law. We also spoke with the local authority regarding the incident which prompted this inspection to get a picture of current concerns.

As part of the inspection process:

We spoke with the registered manager, deputy manager and two operational directors. We also spoke with four support workers, two members of nursing staff, the chef and the activities co-ordinator. We also spoke briefly with additional support staff the provider had temporarily placed at the building who were updating care documentation and reviewing information for staff.

We also spoke with six people who used the service and two relatives whilst at the service, as well as one visiting health professional.

We looked at seven people’s care records, medicine administration records (MAR) and medicines management. We looked at records of accidents, incidents and complaints, records of residents’ and staff meetings. We looked at three staff recruitment records and training and supervision for the staff team. We looked at audits and quality assurance reports.

We asked for feedback from six health and social care professionals about the service, and heard back from four in addition to the health professional we spoke with on the day. We also spoke with three relatives on the phone following the inspection visits.

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 concluded.

Further inspections will be planned for future dates.

Rating at last inspection:

At the last inspection on 8 May 2018 the service was rated Good; the last report was published on 12 July 2018.