This unannounced inspection of Devereux House took place on 17 July 2017. Devereux House provides residential care for older people over the age of 65. It is located above a day centre within a residential area of Farnborough, Hampshire. The home offers a service for up to 16 people. At the time of our visit 11 people were living in the home full time and two people were being supported temporarily with respite care.

We last inspected Devereux House on 11 and 13 January 2016 and found the provider to be in breach of regulations in relation to good governance and fit and proper persons employed. We issued a warning notice for the breach of regulation in relation to good governance. The provider was required to meet the regulation relating to the warning notice by 31 May 2016. During this inspection we found the provider had taken action to ensure the requirements of this regulation had been met.

We served a requirement notice on the provider regarding the breach of regulation in relation to the employment of fit and proper persons. The provider was required to send us an action plan detailing how they were going to make improvements to meet the regulation. During this inspection we found the provider had made some improvements to their recruitment process but there were still some gaps in relation to staff previous employment histories. However, prior to the completion of this report the registered manager had provided evidence to demonstrate that all gaps in staff employment histories had been addressed. In addition the provider had also made improvements to their recruitment documentation to ensure robust processes going forward.

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 were protected from abuse because staff were trained and understood the actions required to keep people safe. Staff had completed the provider’s required safeguarding training and had access to guidance to help them identify abuse and respond appropriately if it occurred. Staff were able to demonstrate their role and responsibility to protect people.

Risks specific to each person had been identified, assessed, and actions implemented to protect them. Risks to people had been assessed in relation to their mobility, social activities and eating and drinking. Staff were able to demonstrate their knowledge of individual risk assessments and how they supported people in accordance with their risk management plans.

People’s care plans had been reviewed to ensure they included all of the information staff required to meet people’s needs.

The registered manager completed a daily staffing needs analysis to ensure there were always sufficient numbers of staff with the right skills mix and experience to keep people safe. We reviewed staff rotas which confirmed that people had been supported by sufficient numbers of suitable staff to keep people safe. Staff had undergone pre- employment checks as part of their recruitment, which were documented in their records.

People received their medicines safely, administered by staff who had completed safe management of medicines training and had their competency assessed annually by the registered manager.

The provider’s required staff training was up to date, including safeguarding people from abuse, moving and positioning, the Mental Capacity Act 2005, fire safety, food hygiene and infection control. This ensured staff understood how to meet people’s support and care needs. Training was refreshed regularly to enable staff to retain and update the skills and knowledge required to support people effectively.

Staff had received individual supervisions and appraisals from their super

We inspected Devereux House on 11 and 13 January 2016. Devereux House provides residential care for older people over the age of 65. The home offers a service for up to 16 people and at the time of our visit 15 people were living in the home. This was an unannounced inspection.

We last inspected the home on 14 November 2013 and found the provider was meeting all of the requirements of the regulations at that time. We did however, report that the provider might find it useful to note that their system of internal auditing did not include follow-up actions plans and that people's risk assessments were not being kept up to date.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 service is required by a condition of its registration to have a registered manager. The manager had been in charge of the home since June 2015 and had started the process to become registered with CQC following our visit.

At the time of our visit a full and effective governance system to monitor the quality of the service and identify the risks to the health and safety of people was not in place. The manager and Board of Trustees monitored the quality of service people received through monthly visits and meetings However, we could not see that these systems were effective in ensuring compliance with the regulatory requirements. Systems currently in place had not identified the areas of concern we found during the inspection so that action could be taken to improve the quality of care and ensure the safety of people.

The required pre-employment information relating to care workers employed at the home had not always been obtained when care workers were recruited. The provider did not ensure that safe recruitment practices had been followed to ensure staff were suitable for their roles.

Staff were able to demonstrate their understanding of the risks to people’s health and welfare and people told us they received care that met their needs. Risks associated with people’s care and support needs had been identified and guidance provided to help staff protect them from harm. However, people’s care records were not always sufficiently comprehensive to ensure staff who were new to the location would have all the information they required to enable them to meet people needs, wishes and preferences.

Staff had received training to support them to effectively meet the individual needs of people. Even though staff felt supported they did not always receive supervision (one to one meetings with their line manager) to ensure they maintained the skills and knowledge needed to meet people’s needs effectively. We have made a recommendation about staff supervision.

People and staff spoke positively about the manager. They felt she was approachable, listened to them and asked for their views. People felt involved in their care. People were supported with activities, and enjoyed time spent with staff.

People were treated with kindness, compassion and respect. Staff promoted people’s independence and right to privacy. The staff were committed to enhancing people’s lives and provided people with positive care experiences.

People knew how to make a complaint. People told us the manager and staff would do their best to put things right if they ever needed to complain. The provider was using learning from a complaint to review whether adjustments to the service could be made so that, in the future, people could continue to live in the home once they had developed dementia.

People received their prescribed medicines when needed and had access to healthcare services when they needed them. People liked the food and told u

On the day of our visit there were thirteen people residing in the service. We were met by the care officer who told us that the manager and assistant manager were away that day. Following our visit both the manager and assistant manager provided us with additional information.

We found that people were always asked for their consent to care on an ongoing basis. People told us that staff always asked their permission before they offered them care. We found that there were no clear procedures in place for assessing a person’s mental capacity.

We found that, overall, people were satisfied with their level of care, and that the provider had an effective system in place for assessing, managing and reviewing people’s needs One person said “they spoil us rotten here”.

We found that staff were trained in safeguarding people from abuse and able to report any incidents of abuse without fear of recrimination from their employer. The people we spoke with said they felt safe from harm.

We found that there were appropriate staffing levels in the service and that staff were qualified for their work. People told us that staff responded quickly to requests for help.

We found that the provider obtained regular feedback from people on the quality of the service, and had systems in place to conduct regular audits and assessments of the whole service. The people we spoke with said that staff members were always asking if they were OK and if they wanted anything.

We spoke with three people who used the service. One person we spoke with said “you’re allowed to do what you want to do. It’s clean and the service is good”. Another person we spoke with said “it’s very good and the staff are very nice and helpful. They care for me well and I get what I want”. The third person we spoke with said “It’s good. The staff look after us well”.

We found people were offered choices and their likes, dislikes and preferences had been taken into account when planning and delivering their care. We found the service had completed detailed risk assessments for people which included detailed action plans for staff to follow in order to minimise risks.

We saw the service had a safeguarding policy in place and staff knew the procedure for reporting possible abuse. We saw the service had procedures in place to ensure medicine was ordered, stored, administered and disposed of safely. The service also had procedures in place to ensure all necessary checks had been performed before staff began work.

People who could express a view told us they liked living at the home. They said that the staff were good.

Several people told us the food at the weekend was poor.

Relatives told us they felt able to raise any complaints and they were confident that there concerns would be responded to and dealt with quickly.

Relatives spoken with told us they were happy with the care their relative received. They told us staff were kind and caring. One relative said "couldn't ask for better staff" and" always a cheery smile from staff when I visit the home" and" my relative is in safe hands".