Inspection on 19/07/05 for Desmond House Ltd

This inspection was carried out on 19th July 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

Desmond House Ltd 18/12/06

Desmond House Ltd 06/06/06

Desmond House Ltd 14/12/05

Desmond House Ltd 01/03/05

Desmond House Ltd 19/07/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Desmond House Limited 16-18 Desmond Avenue Kingston upon Hull East Yorkshire HU6 7 JZ Lead Inspector John Gregory Unannounced 19 July 2005 @ 8.00 am th 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. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Desmond House Limited Address 16-18 Desmond Avenue Kingston upon Hull East Yorkshire HU6 7JZ 01482 448865 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) Desmond House Limited Mr Graham Achmed Care Home 19 Category(ies) of MD Mental Disorder (19) registration, with number MD(E) Mental Disorder - over 65 (19) of places Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The registration category MD(E) is to enable service users already resident in the home to remain there upon reaching pensionable age (as long as the home can continue to meet their needs). Date of last inspection 1st March 2005 Brief Description of the Service: Desmond House is a care home providing accomodation and personal care for 19 persons who are subject to enduring mental health disorders. The category for older people is to allow individuals to make the accomodation their permanent home. The care home is privately owned. The accomodation consits of two ajacent semi detatched houses that have been extended and adapted.It is situated close to Beverley Rd a main thoroughfair into the centre of Hull.The home has 13 single and three double rooms,two of the single rooms and one double room have en-suite facilities.There are two lounges and a dining room. The accomodation has a garden to the rear and a small parking area. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of one morning in July 2005.The inspection was one hour in preparation and five and a half hours in fieldwork. A sample of policies procedures and records were examined relevant to the standards assessed. Four service users case files were examined two of which were case tracked. Four staff files were examined. Three staff members and three service users were individually interviewed. A brief tour of the accommodation was undertaken. The manager Graham Achmed facilitated the inspection. The inspector would like to thank the Manager, staff and service users of Desmond house for their time cooperation and hospitality during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 6 The service provider’s policies procedure and practice for staff recruitment is unsafe and needs to improve to offer the service users proper protection. The detail of the service users care plans needs to be improved, as do the service users risk assessments. This would improve the detail of their day-today care. The service provider should improve the staffing level and offer training to staff in the area of the homes specialism of mental health. The detail of the health and safety processes need to improve. 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. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 7 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 Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 8 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&5 Admission to the home is based on good information for service users and a detailed assessment by staff. This ensures that the home is able to meet the needs of the service user. This process would be enhanced, as would the service users continued stay; by the production of a full contract for service users. EVIDENCE: The service provider has developed a statement of purpose and service users guide, which provides good basic information for service users. Service users were able to confirm having had an assessment prior to admission a copy of which was on file. The service users confirmed that they had a brief short stay before admission and a lengthy trial period of admission in order that both parties accepted the suitability of the placement. The files of all service users were seen to contain the Local authorities contract and a basic service proved contract. However neither contract contained all the information recommended in the national Minimum standards .The written detail of care that underpins their care remains incomplete. A recommendation is made in this matter. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 9 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&9 Four service users case files were examined and none of these contained a sufficient level of detail in either the care plans nor the risk assessments upon which to plan to meet the service users assessed needs. Neither would the information support an independent life style. None the less the service users felt that their needs were met and that they were able to live an independent lifestyle. EVIDENCE: The case files examined contained care plans, which in the main referred only to matters of domestic skills, and personal hygiene. Service users were able to confirm their knowledge of the plan and their agreement to it. Service users were able to describe a fuller lifestyle and discussion of the future, which was not recorded on file. A recommendation is made that the care plans better reflect the service users plans and aspirations. Risk assessments either referred to their being no risks or to specific risks associated with the service users medical condition. Service users were able to describe living a independent life style with risks that were not addressed in the assessment. It is recommended that the written documentation contain a full assessment of their risks in the daily processes of living. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 10 Evidence was seen of a review process with other professionals, which meets the standard of a six monthly review. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 11 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 15 16&17 Some service users due to their mental conditions are difficult to motivate to a high level of activity; others live a full lifestyle involving trips in the area and outside this country. The service users rights to and independent lifestyle are respected. The service users enjoy a good diet with choice available at all meals EVIDENCE: It was observed and some service users and staff confirmed that some of the service uses live a very sheltered life and are difficult to motivate to activity but remain mentally stable. Some service users were able to confirm an independent and active life, which included regular trips outside this country. Service users confirmed that they had visits to local areas of interest and some service users attend a day centre weekly. Service users confirmed that they could come and go as they pleased. And were observed to spend time alone in their own rooms or in company. The menu was seen and was based on a four weekly cycle with choices available at all meals. Service users were able to confirm the choices available and were unanimous in their appreciation of the food on offer. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 12 Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 13 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 &20 Service users do have support sufficient for their basic needs but this is limited by the availability of homes staff to spend time individually with them. Their physical and psychiatric needs are met. The medication procedures protect service uses and only minor attention is needed to its detail. EVIDENCE: The service users all have their individual style and there is much flexibility in the way they spend their days. Service uses were concerned that staff did not have much time to spend with them, as the staff are often preoccupied with housekeeping tasks. This matter is addressed in the section on staffing. There was good evidence on file confirmed by service users of a good input from the psychiatric services to meet their specialist needs. Evidence was also available on file of the involvement of the Primary health care team and ancillary services to ensure that their physical health care needs were met. The medication system was examined and audited. It was basically well managed and the amounts of medication tallied with the records. The manager must ensure that all medication is signed for at the point of administration and a recommendation is made in this matter. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 14 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&23 Service users feel confident that their views are listened to and acted upon. Service users are protected by the homes policies and procedures for the prevention of abuse, which the staffs understand. EVIDENCE: The service provider has a policy and procedure for dealing with complaints with which the staff were familiar. On interview the service uses confirmed that they had confidence that their concerns would be listened to and taken seriously. The service provider has policies and procedures for the prevention of abuse to adults and whistle blowing with which the staff were familiar and were committed to using should the need arise. The service users are offered good protection from abuse. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 15 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&30 The service users live in good well-maintained accommodation that is clean and hygienic and decorated in a domestic manner. EVIDENCE: A brief tour was made of the home and evidence was available that work and repairs had been done to address the requirements of the last inspection. Work was being undertaken during the inspection to more effectively enclose the garden area. The accommodation was clean and tidy and decorated and equipped in a domestic fashion. The laundry was clean with impervious walls and floor. It contained commercial washing equipment and hand washing facilities. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 16 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) 33,34&35 The home does not have a staffing level, which would support all the needs of the service users. The staff are basically trained in practical caring matters but not in issues related to the mental health specialism of the home. The service provider’s recruitment practices and records do not protect service users and are unsafe. EVIDENCE: The home operates on the basis of two care staff per shift with the manager being included in the rota. Service users confirmed observation that there was insufficient staff time to give service users individual time and attention. The service users also commented that matters are very stretched if any of the service users are exhibiting difficult behaviour. The staffing level is that agreed by the previous regulating authority and under current protocols the home is not required to meet the current standard. A recommendation is made that the staffing level be reviewed with a view to making the manager’s hour’s supernumery. The staff are basically trained in care tasks but there is no evidence of any training being offered in the needs of the group of service users with which the home specialises. A recommendation is made in this matter. Five of the homes staff have an NVQ qualification. It is recommended that 50 of staff become qualified as soon as possible. The files of four staff were examined including those of two staff recently Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 17 starting work in the home. Two of the staff did not have a completed application form. Two staff did not have any evidence of identity on file. Only one staff had two references the others no references. All the staff had a CRB check but two were from previous employers and need to be repeated for this employment. None of the staff had made a health declaration. The current recruitment process is unsafe and a requirement is made that the matter be put right within a short timescale. Service users declared belief that the service provider’s recruitment practices protected them was misplaced. It was noted that one staff had a criminal record that may have excluded her from work with vulnerable adults. In these circumstances the appointing officer should identify why they exercised discretion to appoint this person. A recommendation is made in this matter. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 18 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) 39&42 The service users views are central to any planning in the home. The home is a basically safe place to live and work although attention is needed to some mains tests and records. EVIDENCE: The service provider has a basic quality system that puts service users views to the fore in any planning. The Home undertakes good health and safety and fire checks. It is recommended that the home undertakes a work place risk assessment, has a professional check on the water system and keeps detailed COSSH records. Staff and service users were unanimous in feeling safe working and living in the home. Both groups felt that any matters affecting their health and safety brought to the attention of the owners would be immediately rectified. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 19 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 x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Desmond House Limited Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 20 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 YA 34 Regulation 19 Schedule 2 Requirement The service provider must obtain all the following information in respect of person working in the home. -An Application form -Evidence of identity -Two writtenreferences -A current CRB check -A statement by the person as to their Physical and mental health Timescale for action 01/09/05 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. 2. 3. 4. 5. Refer to Standard YA 6 YA 9 YA 5 YA 20 YA 33 Good Practice Recommendations The service provider should develop the care plan for each service user to address all their needs. The service provider should undertake a risk assessment on all service users to cover all aspects of their daily life. The service provider must provide each service user with a contract which meets all the areas described in the National Minimum standards. The service provider should ensure that all medication is signed for at the point of delivery The service provider should review the homes staffing level in the light of the changing needs of service users. J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 21 Desmond House Limited 6. 7. 8. 9. 10. 11. YA 34 YA 35 YA 35 YA 42 YA 42 YA 42 The service provider should record their reasons for appointing staff who may be considered unsuitable to work with vulnerable adults. The service provider should ensure that all staff recieve training in issues related to mental health The service provider should ensure that 50 of care staff are trained to NVQ level 2 as soon as possible. The service provider should undertake a work place risk assessment. The service provider should arrange for routine tests to be undertaken on the water supply The service provider should maintain complete COSSH records. Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. Extracts may not be used or reproduced without the express permission of CSCI Desmond House Limited J54_s44243_Desmond House_v230051_190705_Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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