Desmond House Limited

Updated 12 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Desmond House Limited is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Desmond House Limited is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we received about the service since our last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 9 people who used the service to ask about their experience of care provided. We also spoke with the registered manager, the deputy manager and 3 members of care staff. We reviewed a range of records. This included 2 people’s care records and a range of medicine records. We looked at 2 staff files in relation to recruitment and supervision. We reviewed a variety of records relating to the management of the service. We also spoke with 1 professional who visited the service.

Updated 12 April 2023

About the service

Desmond House Limited is a residential care home providing personal care to up to 18 people. The service provides support to people with mental health needs, learning disabilities and autism. At the time of our inspection 16 people with mental health needs were using the service.

People’s experience of using this service and what we found

At the time of the inspection, the location did not care or support anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

Right care

The provider had made improvements since the last inspection. Infection, prevention, and control was well managed. Staff were trained and understood their responsibilities for maintaining high standards of cleanliness. Staff managed medicines consistently and safely. Staff were competent and trained in the administration of medication. Effective safeguarding systems were in place. Safeguarding concerns were managed consistently and promptly. All staff had an awareness and understanding of abuse and felt comfortable with raising concerns about their own or other people’s safety.

Right Support

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. There was enough competent staff on duty to care for people safely. People were supported to remain safe. Risk assessments were person centred and creative in relation to people’s safety. Staff were aware of people’s risks and how to manage them. Staff understood their responsibilities to raise concerns and report accidents and incidents. Lessons were learned and communicated to staff.

Right Culture

The service had a positive culture that was person centred and empowering. Interactions between staff and people was personalised and relaxed. The provider had clear governance systems in place that identified and managed risk through audits and action plans. These were used to monitor the services performance and drive improvements.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 4 February 2020). At our last inspection we recommended the provider made improvements in infection, prevention and control and quality monitoring. At this inspection we found the provider had made improvements in these areas.

Why we inspected

We carried out an unannounced inspection of this service on 18 December 2019 and the 09 January 2020. We undertook this focused inspection to confirm the improvements had been made. This report only covers our findings in relation to the Key Questions safe and well-led which contain those improvements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Desmond House Limited on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.