Inspection on 16/08/05 for Damascus House

This inspection was carried out on 16th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Damascus House 04/12/08

Damascus House 16/01/07

Damascus House 29/11/05

Damascus House 04/11/04

Damascus House 01/07/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Damascus House 517 Loughborough Road Birstall Leicester LE4 4BJ Lead Inspector Everton Osbourne Unannounced Inspection Tuesday, 16 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Damascus House Address 517 Loughborough Road Birstall Leicester LE4 4BJ 0116 2671173 0116 2671173 None Mr Vincent Kelly Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Jane Kelly Care Home 12 Category(ies) of LD Learning disability(12) registration, with number of places Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No additional Conditions of Registration apply. Date of last inspection 1st July 2004. Brief Description of the Service: Damascus House Care Home cares for 12 younger adults who have learning disability. The premise is located in a residential area about 4 miles from Leicester city centre where residents have access to a variety of shops and other amenities. The home is easily accesible by public and private transport. The premise consists of two floors for residents use which is accessible by use of the stairs. The home has twelve single bedrooms one with ensuite facility. There are sufficient numbers of toilet and bathroom facilities on both floors based on twelve residents residing in the home. A garden with a fish pond and paved area is situated to the rear of the building which is accessible to all residents residing in the home. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took three hours to complete. The outcome of the inspection was positive in that two residents spoken with indicated that they are satisfied with the care provided in the home. One staff member and the registered manager were also spoken with as part of the inspection process. A tour of the premises took place and care records were inspected. No Requirements or Recommendations were made during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 4 and 5. The admission process is good based on detailed information about the service provision in the home. The assessment process is good in giving sufficient information to staff members so that they can meet residents’ care needs. EVIDENCE: An examination of the Statement of Purpose indicated that the home clearly outlines the service provision. Two residents spoken with indicated that they are very satisfied that the standard of care meet their required care needs. One resident’s assessment was examined and the document contained sufficient information in identifying the resident’s care needs. One resident’s admission record seen indicated that a contract of residence is given to the resident outlining the Terms and Conditions of their residency in the home. Discussion held with the registered manager and one resident’s care record seen indicated that prospective residents have an opportunity to visit the home before a choice is made about where to reside. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 10. Residents care plans are written in detail so that they receive the care they need. Good consultation processes are in place so that residents have the independence they need. EVIDENCE: Detailed inspection of one resident’s care plan indicated that all aspects of personal and health care needs including recreational needs are recorded in the document. Care plan records seen and discussion held with the registered manager indicated that the document is reviewed on a regular basis. Two residents spoken with indicated that they make plans about their daily activities with support from the staff team and registered manager. For example one resident indicated that it is his choice when to participate in recreational activities in and away from the home. Observations made throughout the day indicated that staff members consult with residents about decisions made in the home for example what and when to eat. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 and 17. The home provides good opportunities for residents to access leisure and educational facilities. Residents maintain good links in the community and have satisfactory choices concerning their daily lives. EVIDENCE: One resident spoken with indicated that he currently attends day care for leisure and educational activities. His care plan seen including his risk assessment confirmed that he attends day care three days each week. One resident’s daily records seen indicated that his daily routine includes regular contact with relatives and friends. One resident commented ‘I’ve got brothers and sisters and they take me out’, indicating that they take her out on day trips. Discussion held with two residents and one staff member indicated that meals are varied and wholesome and given to the residents according to their choice. The menu seen confirmed their verbal statements. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Suitable processes are in place to meet residents’ hygiene care, which include provisions for meeting their health care needs. The medication process works well in ensuring that residents receive their medication at the times prescribed. EVIDENCE: Two residents spoken with indicated that support is given by the staff team to ensure that their hygiene care needs are met. One resident’s daily care record seen confirmed the residents’ verbal statements. Detailed examination of one resident’s care record indicated that healthcare professionals such as Community Nurses and General Practitioners form part of the care process. Two residents spoken with indicated that they access doctors and other professionals located in the community as part of their ongoing care. Conversation held with two residents and that support is given to residents to ensure are followed for residents’ safety. The sufficient information for staff members’ medication. the registered manager indicated that correct medication procedures medication policy seen contains guidance concerning safe use of Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Good processes are in place so that residents or their relatives can make a complaint if required. An adult protection process is in place for the protection of residents residing in the home. EVIDENCE: Detailed examination of the written complaint process indicated that clear guidance is given to residents and their relatives on how to make a complaint. One resident spoken with gave sufficient verbal responses on how to make a complaint and whom to contact to make a complaint. The adult protection process was inspected. Clear guidance is written in the adult protection policy for staff members’ guidance on how to reduce the risks associated with abuse to vulnerable people. Both residents spoken with indicated that they feel safe residing in the home. One staff member spoken with gave good verbal responses pertaining to good adult protection. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27 and 30. The home is clean throughout and maintained to good standard with an emphasis on comfort for residents. EVIDENCE: An inspection of the flooring, walls and fixtures throughout the home indicated that it is being maintained to good standards. Two residents spoken with indicated that they are satisfied with the upkeep of the premises. The number of bathing and toilet facilities seen in the home indicated that they are sufficient in numbers based on twelve residents sharing the facilities. Two residents spoken with indicated that they are satisfied with the cleanliness of the home. The infection control policy seen contain good information for staff members’ guidance on how to maintain safe hygiene practices for example good hand washing techniques which was observed during the inspection. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33. The care hours provided in the home is sufficient in providing suitable care and protection for residents residing in the home. EVIDENCE: The staffing rota was examined and it indicated that sufficient skill mix and staffing hours are provided on a daily basis. Observations made and discussion held with the registered manager indicated that there are staff members on duty even at times when residents are away from the home attending day care. Two residents spoken with indicated that staff members are always available in the home. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 41 and 42. The procedures and written policies seen are sufficient in providing good guidance for staff members. Good record keeping is maintained in the home in accordance with written guidance for the protection of residents. EVIDENCE: All policies inspected were found to be up to date with good guidance for staff members employed to work in the home. One staff member spoken with had good knowledge of the home’s policies. One resident’s care records seen for example the care plan was found to be up to date for the care and protection of the resident. Fire safety procedures inspected were found to be in good order for example fire safety equipments and records. Discussion held with the registered manager and the fire safety records seen indicated that regular fire drills and testing of the fire alarm are carried out on a regular basis. Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Damascus House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x 3 3 3 x C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 16 None Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation None Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard None Good Practice Recommendations Damascus House C51 C01 S1785 Damascus House V243880 160805 STAGE 4.doc Version 1.40 Page 17 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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