Archived: Devonshire Court

Updated 31 May 2017

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

We undertook an unannounced inspection of Devonshire Court on 16 March 2017. The inspection team consisted of three inspectors, a specialist pharmacy advisor and an expert by experience (ExE). An ExE is a person who has personal experience of using or caring for someone who uses this type of care service. We spoke with 10 people and four relatives of people who used the service.

During our inspection visit we spoke with 12 staff members employed by the service. This included the facilities manager, the domestic supervisor, an activities coordinator, the finance manager and five care workers. We also spoke with the registered manager, acting deputy manager and the regional operations manager. Two health care professionals were visiting and we spoke with them to gain feedback about the service.

We looked at the care records of seven people who used the service at the time of our inspection. We looked at three staff recruitment files to see how the provider recruited and appointed staff. We also looked at records associated with the provider’s monitoring of the quality of the service and staff training.

We observed care and support provided in the communal areas of the service. This was so that we could understand people’s experiences. By observing the care received, we could determine whether or not people were comfortable with the support they were provided with.

Since our last inspection, the provider had sent us weekly updates on actions that they had taken to make improvements. Before this inspection we reviewed notifications that we had received from the provider. A notification is information about important events which the service is required to send us by law. We contacted health and social care professionals who have contact with the service to gain their views of how the service was run and about the quality of the care and support provided. We also contacted Healthwatch Leicestershire who are the local consumer champion for people using adult social care services to ask them for feedback.

Updated 31 May 2017

We inspected Devonshire Court on 16 March 2017. This was an unannounced inspection. This meant that the staff and provider did not know that we would be visiting.

At our last inspection of the service on 10 and 11 August 2016 the provider was failing to meet four regulations. These related to governance, safe care and treatment, the submission of statutory notifications and safeguarding service users from abuse and improper treatment. This service was placed in 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. During this inspection the service demonstrated to us that improvements have 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.

Devonshire Court provides residential care for older Freemasons and their dependants. Prior to our inspection the service had also been providing nursing care for people. The provider had applied to remove nursing care from their registration. This was effective from 6 March 2017. The home is registered to accommodate up to 69 older people and there were 40 people using the service on the day of our inspection visit.

Within the home there are two units providing a specialist service for older people living with dementia. These are Sherwood and Rutland which currently have capacity to support 10 people each. These units have their own lounge, kitchen and dining area. Other accommodation is provided over two floors. There is a large communal dining room, lounge, conservatory, library and activity room. There are also smaller lounges/dining areas throughout the accommodation.

The service 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us that there were not enough staff to meet their needs. Staff confirmed that in some areas of the home this was the case. The registered manager told us they would review the deployment of staff to make sure people received the care when they needed it.

Staff were aware of how to report and escalate any safeguarding concerns that they had within the service and, if necessary, with external bodies. Safe recruitment practice was followed.

People received their medicines safely. Systems were in place to monitor the health and wellbeing of people who used the service. People’s health needs were met and when necessary, outside health professionals were contacted for support.

People were protected from avoidable risks. Risks associated with people’s care were assessed and managed to protect people from harm. The environment was maintained to keep people safe. Regular safety checks had been carried out on the environment and the equipment used for people’s care to ensure that they were safe. Staff understood how to follow these.

Staff had received training and supervision so that they could meet the needs of the people who used the service. Staff told us that they felt supported.

People were supported in line with the requirements of the Mental Capacity Act 2005. Where people were assessed as lacking the mental capacity to make informed decisions, these were made in their best interest on their behalf.

People enjoyed the meals provided and where they had dietary requirements, these were met.

People’s independence was promoted and people were encouraged to make choices. Staff treated people with kindness and compassion. Dignity and respect for people was promoted.

People were supported to remain active and offered opportunities to engage in activities that were of interest and meaningful to them.

People received care that was centred on them as individuals. People’s care needs had been assessed and were reviewed to make sure they continued to be met. Staff had a clear understanding of their role and how to support people who used the service.

People were given opportunities to feedback about the service they received. Action had been taken based on people’s feedback. Complaints were addressed in line with the provider’s policy.

People and staff felt that the registered manager was approachable and action would be taken to address any concerns they may have.

Action had been taken to make the required improvements following our last inspection in relation to monitoring the quality of the service. Systems were in place to measure the quality and care delivered. However these had not yet had time to fully embed to demonstrate that improvements were sustainable. The provider supported the registered manager in their role and monitored the service to make sure that people received care in line with their policies and procedures.

The registered manager understood their responsibilities for reporting incidents or events that happened in the service to CQC and other agencies.