Archived: Devonia EMI Home

Updated 11 June 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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 focused inspection of Devonia EMI Home on 1 March and 2 March 2016. The purpose of this inspection was to check that improvements to meet legal requirements had been made. The team inspected the service against two of the five questions we ask about services: Is the service Safe? and Is the service Well-led?

An inspector and an inspection manager undertook this inspection.

Prior to our visit we reviewed four previous inspection reports, , safeguarding information received from the local authority and notifications received from the provider about a failure of the home’s boiler and Deprivation of Liberty Safeguards (DoLS) that had been authorised. A notification is information about important events which the service is required to send us by law. This enabled us to ensure we addressed potential areas of concern.

We observed care and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We looked at care records for all three people living at the home, medication administration records (MAR), monitoring records of people’s weights, accident and activity records. We also looked at two staff recruitment files, four staff training files, staff rotas, staff handover records and audits of the service.

During our inspection, we met with all three of the people who lived at the service although only one person was able to provide detailed information about their experiences. We also spoke with one relative, the provider and five care staff. Following the inspection, we contacted a Community Psychiatric Nurse (CPN) who had involvement with people at the service to ask for their views and experiences.

Updated 11 June 2016

We carried out an unannounced focused inspection of this service on 1 and 2 March 2016. The first part of the inspection was conducted ‘out of hours’ because we had concerns about night staffing levels. We undertook this focused inspection to assess the level of risk to people’s safety and welfare and to review whether the provider now met legal requirements. The provider had been in breach of regulations since September 2014 and had failed to respond appropriately to meet requirements. This inspection identified continued breaches of legal requirements and found that people were at continued risk of harm.

During this inspection we considered the domains of ‘Safe’ and ‘Well-led’ and reviewed seven of the nine breaches of regulations identified at our November 2015 inspection. Of the seven breaches reviewed, five remained unmet. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Devonia EMI Home on our website at www.cqc.org.uk

Devonia EMI Home is a family-run home that has been established for over 30 years. It provides accommodation and care for up to 12 ladies, over the age of 65, some of whom are living with dementia. At the time of our visit there were three people in residence and the provider had agreed to a voluntary suspension on new admissions due to on-going failures to meet requirements of the regulations.

The service did not have a registered manager and the provider was in breach of their registration conditions. 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. The previous registered manager had deregistered with us in September 2014 and had not worked at the service since May 2014. The service did not have a manager at the time of this inspection and the day-to-date running of the service was being managed by the provider.

There was a lack of effective leadership. The provider had been in breach of regulations since September 2014. They did not have a system to assess, monitor and improve the quality and safety of the service or to respond to known risks.

People were at risk of harm. The provider had failed to assess risks to people’s safety and to provide staff with the necessary guidance and training to meet their needs. Some people who used the service presented on occasions with behaviours that could be described as challenging. Staff had not been trained in how to support people with these needs and there was insufficient guidance on the use of medicines prescribed on an ‘as needed’ basis to manage behaviours. Where people needed support to move, some staff had not been trained in safe moving and handling procedures and staff did not always use mobility aids to promote safe practice. Records relating to people’s care and to the management of the service were not always accurate.

There were enough staff on duty but some staff had not received training to enable them to support people in a safe way. Although the staff on duty were able to describe how they would identify and respond to any allegation of abuse, some staff had not received training in safeguarding adults at risk.

The provider failed to notify the Commission of significant events as required by law. They had not displayed the rating of the service given at the last inspection. Services are required to display their rating so that people can easily understand the performance of the service.

Relatives spoke highly of the service and staff. During our visit there was a calm atmosphere. There was very little by way of activity or stimulation for people.

People received their medicines safely and staff followed clear procedures for the management and storage of medicines.

There were systems in place to promote safe recruitment decisions and to assess whether new staff were safe to work with adults at risk.

The provider had taken action to improve fire safety equipment and processes within the service following action taken by the Fire Service.

We found five continued breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. Two breaches from the inspection in November 2015 were not reviewed as part of this inspection.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

CQC has now cancelled the provider's registration.