CARE HOME ADULTS 18-65
Agape Annexe 191 Havelock Street Kettering Northants NN1 8QR Lead Inspector
Mr Keith Williamson Key Unannounced Inspection 12 March 2007 09:00 Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 1 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 Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 2 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 Stationery 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. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Agape Annexe Address 191 Havelock Street Kettering Northants NN1 8QR 01536 510808 01536 390608 enquiries@agapehomes.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Hamilton Mrs Julia Rosemary Hamilton Mrs J Hamilton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The Home will limit its services to the following service user categories: No person falling within the category LD can be admitted where there are already 3 persons of category LD in the home. No person under the age of 18 years or of/over the age of 65 years may be admitted to the home. The total number of service users in the Home must not exceed 3. Date of last inspection 30th January 2006 Brief Description of the Service: Agape Annexe is a care home providing personal care and support for three people with learning disabilities. The service is aimed at adults with low levels of dependency who may be working towards a move into greater independent living in the future. Agape Annexe is one of three care homes within walking distance of each other, owned by Mr and Mrs Hamilton. The home is situated on the outskirts of Kettering close to shops, other local facilities and the bus route to the town centre. The property is a terraced house offering 3 single bedrooms for the service users and one staff bedroom, one bathroom and shower facilities, a kitchen and living / dining room. To the rear of the property is a further house where the main office is located and many records are stored. The current fees charged weekly fall between £319 and £450 per week, there are additional charges for hairdressing. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, involving reviewing the last inspection report, review of the events that have taken place since the last inspection, review of the pre-inspection questionnaire and the self assessment document. The unannounced site visit commenced on the 13th March 2007 and lasted seven and one half hours. The focus of the inspection is based upon the outcomes for the Service Users. The method of inspection was ‘case tracking’. This involved identifying new and existing Service Users with varying levels of care needs and looking at how these are being met by the staff. Three Service Users were selected and discussion held with them to ascertain their views about the care provided. The method of case tracking included the review of Service Users’ individual care records. Discussions were held with staff regarding delegated responsibilities within the service and reviewing the records, training records, key policies and procedures for the service. The inspection also involved a looking at the office layout and the storage of information; where the day-to-day operations take place, review of the records including complaints, compliments and the safeguarding of children and adult issues. Comment cards sent out to Service Users, comments from those and comments passed to the inspector form part of this report. What the service does well:
Service Users needs are assessed prior to moving into the home. The case tracked Service Users files were viewed; and completed contracts were in place. The care plans and records of all three Service Users were viewed. The care plans contained information as to how the care needs of each Service Users were to be met; these were backed up by specific care tasks and personal goals, and were reviewed regularly. Service User participation in the home has commenced with regular Service User meetings and questionnaires being circulated to the Service Users. Personal development is recognised in each Service Users’ weekly timetable. Daily routines and mealtimes are reflective of individual Service User lifestyles and taste, and are designed to suit the Service Users needs. Service Users are encouraged to retain contact with relatives and friends. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 6 The monitoring of Service Users healthcare is undertaken, and visits from medical staff and General Practitioners is undertaken flexibly and recorded individually. Medication is administered appropriately. The Registered Manager has the necessary complaints procedure and policies in place. There have been no complaints recorded since the last inspection of this service, and none forwarded to the commission for social care inspection. Examination of the adult protection policy indicated that sufficient information is contained in the document for staff members’ guidance on how to prevent abuse in the home. The environment of the home is good and has a friendly relaxed feel. Bedrooms are all single occupancy, are individually decorated and personalised to include a range of personal electrical equipment. The staff turnover at the home is low and this provides Service Users with continuity and consistency of care. The staff member spoken with confirmed that she received supervision and support from the manager. Service Users felt the staff group were approachable, and commented that they had daily contact with the manager. Service Users felt that their opinions were listened to, valued and acted upon and that they had trust and confidence in the staff group as a whole. Fire safety was well maintained with weekly fire tests and regular drills carried out. Staff confirmed that they assisted in the completion of these routine tests. Comments received from Service Users, carers and parents comment cards included: “They (staff) always offer us a great deal of respect”. Comment cards were forwarded to parents and carers but none were returned. Verbal comments received from Service Users at the inspection included: “The staff can’t do enough for us” “I visit my friends, but they don’t come here, I have not asked” “I like Y, (staff), he makes us laugh” “I like playing my music centre, in my room” “Z (staff) is like a grandmother to us” “I go to A (place) to see my sister, and B (relative) comes here to see me” “I like going to ASDA on a Thursday, to do the shopping” Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 7 Written comments received from Health and Social care staff on what the home does well included: X (Service User) has made a huge improvement in all areas of his abilities since placed in this house. I have no concerns around his care and am confident he will continue to receive a high standard of care. 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. The summary of this inspection report can be made available in other formats on request.
Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is detailed and effective resulting in accurate information for prospective Service Users. EVIDENCE: Service Users needs are assessed prior to moving into the home. The manager compiles information using the health and social care assessments, providing an information base from which care plans are then produced. The case tracked Service Users files were viewed; and completed contracts were in place. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are looked after well in respect of their individual personal care needs. EVIDENCE: The care plans and records of all three Service Users were viewed. The main care plans contained information as to how the care needs of the Service Users were to be met. These plans were compiled by the placing social workers, at the time of admission or the last review. Further personal goals were then compiled for each Service User in the form of basic guidelines for staff to follow. These were backed up by specific care tasks, compiled for each Service User and available to staff. Care plans are discussed with Service Users though none of the plans were signed to indicate agreement with the plan. Care plans could be developed into Person Centred Plans (pcp’s) thus enhancing Service Users choice, and staff ‘s knowledge of Service Users.
Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 11 Decision-making and autonomy is covered in care plans, though this could be expanded on, and pointers given to staff on how to promote Service User choice. Service Users commented on attending the weekly shopping trip one stating, “I like going to ASDA on a Thursday, to do the shopping”; this reinforces choice and autonomy within Service Users lives. Care plans are held in the office, with other sensitive information being appropriately secured in the home. Service User participation in the home has commenced with regular Service User meetings and questionnaires being circulated to the Service Users, though a wider group of relatives and professionals could also be involved with this process. Risk assessments are in place, but require to be in greater detail than currently on file, this would offer Service Users a greater degree of safety both in and out of the home. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users experience an appropriate and fulfilling lifestyle. EVIDENCE: Personal development is recognised in each Service Users’ weekly timetable, these being produced from information in the care plan. Weekly timetables are personalised and shared with the Service Users prior to commencement, and also covers evening leisure activities. All three Service Users currently undertake specific college courses or day centre activities. Daily routines are reflective of individual Service User lifestyles, and are designed to suit the Service Users needs.
Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 13 Meals and mealtimes are flexible and are produced to suit the individual Service Users taste and choices. Service Users are encouraged to retain contact with relatives and friends in the greater community. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users health and personal care needs are met on an individual basis. EVIDENCE: Personal support is offered on a flexible basis, care plans reflect what support Service Users require through goal planning; these “goals” are reviewed and updated three monthly. The monitoring of Service Users healthcare is undertaken, and visits from medical staff and General Practitioners is undertaken flexibly and recorded individually. Medication is administered appropriately, the staff when spoken with, showed a good awareness of administration techniques. Medication is stored securely, the medication administration records (mar charts) being up to date, signed appropriately and having no omissions. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are protected by the policies and procedures regarding complaints and adult protection, held in the home. EVIDENCE: The Registered Manager has the necessary complaints procedure and policies in place. Staff spoken with demonstrated a good awareness of both the complaints and adult protection policies and procedures, and how these policies operated. There have been no complaints recorded since the last inspection of this service, and none forwarded to the commission for social care inspection. Detailed examination of the adult protection policy indicated that sufficient information is contained in the document for staff members’ guidance on how to prevent abuse in the home. The manager stated that this was openly discussed at Service User and staff meetings. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users live in a homely, comfortable and clean environment. EVIDENCE: The environment of the home is good and has a friendly relaxed feel. The maintenance and decor of the home is of a good standard, with a plan for redecoration. Bedrooms are all single occupancy, are individually decorated and personalised to include a range of personal electrical equipment. Service Users also benefit from having individual bedroom keys, thus affording the choice of private time alone. The type of lock does require some adjustment to comply with basic safety standards. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 17 The public areas of the home provide a homely comfortable atmosphere. Staff showed a good awareness of cross contamination issues, with laundry facilities being appropriately sited and domestic in nature. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 18 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager provides adequate training, resulting in a competent and supportive staff group who promote and protect the well being of Service Users in their care. EVIDENCE: The staff turnover at the home is low and this provides Service Users with continuity and consistency of care. A number of the staff group have completed or commenced National Vocational Qualifications at levels two and three. A sample of staff rotas showed that appropriate numbers of staff are on duty at all times, for the current Service User dependency levels, this includes a sleeping in night worker. A thorough recruitment procedure is followed with references and criminal record bureau clearances being obtained prior to new staff working with Service Users. The Registered Manager and Inspector discussed staff who require visas to work in this country, the Manager showing an awareness of his
Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 19 responsibilities in this area. Staff files are held securely in the Managers’ office. Staff are provided with comprehensive training and the training plan showed that this included induction and core training enabling staff to care for Service Users consistently. Staff are encouraged to undertake National Vocational Qualifications, again offering further consistency in caring for Service Users. The staff member spoken with confirmed that she received supervision and support from the manager. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 20 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Management of the home is effective, accessible and responsive to the needs of both the Service Users and staff. EVIDENCE: Service Users felt the staff group were approachable, and commented that they had daily contact with the manager. Service Users felt that their opinions were listened to, valued and acted upon and that they had trust and confidence in the staff group as a whole. Service Users confirmed they were involved in the quality assurance of the home by participating in occasional questionnaires and monthly Service User group meetings. The Inspector discussed with the Registered Manager the possibilities of parents and
Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 21 professionals being involved in the homes’ quality assurance questionnaires and feedback. A selection of records including fire and accident were inspected. Fire safety was well maintained with weekly fire tests and regular drills carried out. Staff confirmed that they assisted in the completion of these routine tests. Records were safely and securely held within the office and parts of the home. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No. 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 YA9 Regulation 12 (2) Requirement Risk assessments must be detailed sufficiently to reduce risk to Service Users in the home, and inform staff of what action to take in an emergency situation occurring. Bedroom door locks must be of a suitable type, to allow staff entry to the room in emergency circumstances. Timescale for action 30/04/07 2 YA24 23 (1) a 30/04/07 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 YA6 Good Practice Recommendations Care planning should be developed to produce Person Centred Planning (pcp’s) for all Service Users. Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Agape Annexe DS0000012678.V326694.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
