CQC report explained · a residential care home
What the CQC found at Devonshire Dementia Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2020
Devonshire Dementia Care Home was rated Good; inspectors found kind, safe care, with minor record-keeping improvements needed.
This was an unannounced inspection on 08 January 2020. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicine records, staff recruitment files and management documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated with dignity, received their medicines safely, had suitable food and activities, and were supported to access healthcare.
There were some minor problems with records, including risk guidance, staff employment histories, supervision records and care plan audits. The provider took prompt action, including sending improvement plans and updating procedures. Inspectors said more time was needed to check that the improved quality checks were sustained.
Kind and respectful care
People and relatives said staff were kind and caring. Inspectors saw staff protect privacy, ask permission before entering rooms and support people sensitively.
“People and relatives told us that staff were very kind and caring.” from the report
Safe medicines
Inspectors found that medicines were given at the right times. Records had no omissions, stock checks were carried out and staff medicine skills were assessed.
“People's medicines were safely managed to ensure they received them at the right times.” from the report
Personalised dementia care
Care records included people's preferences and life histories. Staff used individual approaches, communication aids and activities to support people's needs and interests.
“Care records were personalised to reflect people's individual choices and preferences.” from the report
Activities and community links
People could take part in painting, music, exercise, gardening, outings and sensory activities. They could also use the attached day centre.
“A range of activities were on offer to people, as well as accessing the attached day centre.” from the report
Prompt response to inspection findings
The provider acted quickly when inspectors identified record and infection control issues. Updated action plans and evidence of improvements were provided after the inspection.
“The provider took prompt action to remedy these the following day.” from the report
Risk guidance was not detailed enough
needs fixingSome risk assessments identified risks but did not give enough detail about how staff should support people safely. The provider sent an updated action plan the next day.
“However, whilst there was guidance on how to safely support people this could have been more detailed.” from the report
Some staff records were incomplete
needs fixingSome staff files did not contain a full employment history. The provider instructed staff to complete this information after the inspection.
“Not all of the staff records we viewed included a full employment history.” from the report
Gaps in supervision records
needs fixingSome records did not show that staff supervision and appraisals had been completed. The provider said these would be completed by February 2020.
“However, we found some gaps on supervision and appraisal records.” from the report
Quality checks needed to be sustained
needs fixingCare plan audits did not always clearly set out actions for improving records. New checks had been introduced, but inspectors needed more time to see whether they would continue.
“The provider had recently introduced an improved care plan audit, however more time was needed to ensure these improved checks were maintained.” from the report
Infection control procedure changed during inspection
minorInspectors saw staff entering the kitchen to make tea instead of using the tea station. The provider introduced an updated procedure and arranged for the kitchen floor to be replaced.
“We observed staff entering the kitchen area to make tea, rather than use the tea station.” from the report
- 01How have you checked that the updated risk assessments now give staff enough detail to support people safely?
- 02Have all staff employment histories, supervision records and appraisals now been completed?
- 03How do your current care plan audits record clear actions and show that improvements are being sustained?
- 04What infection control procedures are now used for making drinks, and was the kitchen floor replaced as planned?
- 05Which activities, outings and communication methods would best match my relative's dementia needs and preferences?
This was an unannounced inspection covering all five CQC questions, including care, the premises and management systems. This explanation was written from the published report of 11 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2017
The Devonshire Care Home was rated Good; inspectors found safe, kind and personalised care, with no breaches reported.
This was an unannounced comprehensive inspection on 31 May 2017. Inspectors spoke with people living at the home, visitors, staff and managers. They reviewed care records, medicines records, staff files and management records. They also observed care, including during lunch.
The home supported up to 33 older people living with dementia, with 31 people living there at the inspection. Inspectors found people were safe, treated with dignity and supported by staff who knew their needs and preferences. Medicines were managed safely, staffing levels were suitable, and the home was clean and well maintained.
People received support with food, drink, health care, activities and contact with family and friends. Care plans were reviewed and updated. Inspectors also found improvements since the previous inspection, including better access to managers, clearer care records and more regular reviews of people's needs.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home remained Good, the same overall rating as at the March 2015 inspection.
Safe staffing and medicines
Inspectors found enough staff to support people safely. Medicines records showed no gaps or omissions, and staff had their competence checked.
“There were enough staff to support people.” from the report
Personalised dementia care
Staff knew people well and care plans described their histories, choices and preferences. Needs were reviewed monthly or sooner when they changed.
“People's support plans were current and contained clear information about their life histories, their likes and dislikes and their specific preferences and choices” from the report
Respect and independence
Staff supported people to make choices and do as much as they could for themselves. Inspectors saw privacy and dignity being maintained during personal care.
“People were treated with dignity, respect and staff ensured they had privacy when this was needed.” from the report
Activities and family contact
People could take part in varied activities, listen to personalised music and go on outings. Visitors were welcomed and families could visit when they wished.
“There were a wide range of planned activities in the home each day that people could participate in” from the report
Improving management
A new registered manager had been formally appointed since the last inspection. Inspectors found better manager visibility, clearer records and more frequent reviews of people's needs.
“Since our last inspection the visibility and accessibility of managers on duty had improved.” from the report
Inspectors raised no specific concerns in this report.
- 01What has changed at the home since the 31 May 2017 inspection?
- 02How will you assess and review my relative's risks, such as falls, choking or poor food and fluid intake?
- 03How will you support my relative's dementia-related communication needs, preferences and independence?
- 04What activities and outings would be suitable for my relative, and how often could they take part?
- 05How are medicines checked, and how will you tell us about any changes or concerns?
This was an unannounced comprehensive inspection covering all five CQC areas: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 22 June 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Devonshire Dementia Care Home
3 rated inspections over 5 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Devonshire Dementia Care Home →
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Devonshire Dementia Care Home →
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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