CQC report explained · a residential care home
What the CQC found at Devonshire House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2023
Rated Good; inspectors found safer systems, kind staff and improved management, although occasional medicine errors were recorded.
This was an unannounced focused inspection on 07 February 2023. One inspector and one Expert by Experience spoke with people living in the home, relatives and staff. They reviewed care, medicine, recruitment and management records.
Inspectors found that people were safe and that staff were kind and respectful. Risks, accidents, falls and injuries were recorded more clearly. Medicines were stored and given safely, although occasional errors were recorded and reviewed.
The home had acted on problems found at the previous inspection. Its overall rating improved from Requires Improvement to Good. The Safe and Well-led ratings also improved to Good, and the provider was no longer in breach of the regulations previously identified.
Improved safety systems
Records for accidents, falls and injuries were clearer. Risk assessments and care plans gave staff better guidance and were checked by senior staff.
“Since our last inspection clear systems were in place to record events for each individual.” from the report
Kind and reassuring staff
People, relatives and inspectors described staff positively. Staffing levels allowed people to receive care on time, while staff still had time to talk with them.
“All staff from every department were well thought of and words such as , 'fantastic, lovely and kind' were used to describe them.” from the report
Better management oversight
The home had acted on the previous inspection and its quality checks were more effective. Staff said they felt supported and were proud to work there.
“Improved governance was identified at this inspection across all areas.” from the report
Safe medicines management
Medicines were stored and given safely. Staff were trained and assessed as competent, and the home used medicine-error reviews to make changes.
“We saw evidence of learning from medicines errors and changes put in place to ensure incidents were not repeated.” from the report
Occasional medicine errors
minorThe report records occasional errors with medicines. These were logged and managed, but families may want to ask how often they happen and how the home prevents them.
“Occasional medicine errors were logged and handled in a way that would have led to learning and improvements.” from the report
- 01How are you maintaining the improvements made after the previous inspection?
- 02How many medicine errors have occurred recently, and what changes were made because of them?
- 03How will the change from the current manager to the newly appointed manager be managed?
- 04How are falls, accidents and injuries recorded, reviewed and followed up?
- 05How do you check that staffing levels remain enough for people's assessed needs?
This was a focused inspection covering Safe, Responsive and Well-led, with infection prevention and control also checked; ratings for questions not inspected were carried over from the previous inspection. This explanation was written from the published report of 8 March 2023 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 2022
Requires Improvement; inspectors found safeguarding and management weaknesses, although staffing, medicines and infection control were generally safer.
This was an unannounced focused inspection on 5 and 13 April 2022. Inspectors looked only at Safe and Well-led because of concerns about falls, medicine errors and unexplained bruising. They spoke with people, families and staff, and reviewed care, medicine, recruitment and management records.
The home was rated Requires Improvement overall. Safeguarding procedures were not always followed after unexplained bruising and other injuries. Some risk assessments and care plans were out of date. The quality checks did not reliably find these problems, and action plans were not always clear.
There were also positive findings. Staffing levels were considered sufficient, medicines were generally managed safely, and infection control arrangements were found to be satisfactory. The home took some immediate action after inspectors raised concerns and was asked to send an improvement plan.
Staffing
Inspectors found there were enough staff to keep people safe and provide care in a timely way. Recruitment checks for permanent staff had been completed.
“There were sufficient staff to ensure that people were safe.” from the report
Medicines
Medicine stocks and records matched, showing that people received medicines as prescribed. The home had also learned from previous medicine errors.
“The records and levels of stock tallied to show that people received their medication as prescribed.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infection, including visitors, protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Working with others
The home worked with the local authority to reduce medicine administration errors, and this action had been successful.
“The registered manager provided an action plan to reduce the number of errors and this had been successful.” from the report
Safety records were incomplete
seriousSome risk assessments and care plans did not contain current information. Falls assessments did not consider whether medicines might increase the risk of falling.
“Systems were not robust enough to demonstrate safety was effectively managed. This placed people at risk of harm.” from the report
Quality checks missed problems
seriousAudits did not always identify concerns found by inspectors, and action plans did not clearly say who was responsible or when actions should be finished.
“The provider's quality assurance system had not always been effective at identifying areas for improvement and ensuring action was taken in a timely manner.” from the report
Reporting concerns
needs fixingSome staff told inspectors they were not always willing to report concerns to management. The home had held a meeting to remind staff about reporting expectations.
“Staff raised concerns that there was a lack of willingness to report concerns to the management team.” from the report
- 01How are unexplained bruises, blisters and other injuries now referred to safeguarding teams and healthcare professionals?
- 02How do you check that falls assessments include medicines that may increase a person's risk of falling?
- 03How do you make sure care plans and risk assessments are updated after advice from health professionals or changes in a person's needs?
- 04Who is responsible for each improvement action, and how do you record when it has been completed?
- 05How can residents, relatives and staff report concerns directly to management, and what happens after a concern is raised?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 9 June 2022 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 House
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2019Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- March 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2017
Registered with the Care Quality Commission on 6 February 2017.
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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23 live-in carers within about an hour of Suffolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 17 can care for a couple. 7 years' experience on average.
“Not only was she professional, polite and efficient but she bought a lovely smile and laughter to my parents home.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.