Inspection on 02/09/05 for Agape Annexe

This inspection was carried out on 2nd September 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

Agape Annexe 04/03/09

Agape Annexe 12/03/07

Agape Annexe 30/01/06

Agape Annexe 06/01/05

Agape Annexe 23/06/04

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

CARE HOME ADULTS 18-65 Agape Annexe 191 Havelock Street Kettering Northants NN16 8QR Lead Inspector Judith Roan Unannounced 2 September 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. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Agape Annexe Address 191 Havelock Street Kettering Northants NN16 8QR 01536 510808 01536 390608 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) Mr Michael Hamilton Mrs J Hamilton Care Home 3 Category(ies) of LD Learning disability x 3 registration, with number of places Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The Home will limit its services to the following service user categories: No person falling within the category LD can be admitted where there arealready 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 6-Jan-2005 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. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 1 resident and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Staffing and health & safety records are kept in the offices to the rear of the property for the 3 homes which the inspector was able to examine. The inspection took place during the late afternoon, over a period of 2.5 hours and was carried out on an unannounced basis. What the service does well: What has improved since the last inspection? What they could do better: Risk assessment need to be included within the service users file and the care plan need to show both general and individual specific to a service user. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 6 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. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 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 Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 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) 2,3,4 Assessments ensure that service users have choice and know that their needs will be met. EVIDENCE: Service users were able to confirm that they had met with staff prior to admission to identify their needs. Information gained by the home enabled the staff to make a decision as to whether they could meet the individual needs. Service users had had the opportunity to visit the home before they made the decision to stay. Files seen confirmed for the inspector that assessments were undertaken prior to service users being admitted. The inspector discussed with the registered manager how the service could be improved with more information from health and social; care professionals. The development of an assessment tool would enable the staff team to clearly identify whether the home was able to meet the service users needs. Records need to ensure that risk assessments demonstrate how the staff are to minimise the risks. The registered manager has undertaken general risk assessment that cover a range of activities, these are held at the main office. In discussion with the manager it was agreed that both general and specific risk assessments must be included within individual files. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 9 Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6.7,8,9 Care plans demonstrate that service user involvement is an essential part of work practices at the home. Risk assessments do not fully demonstrate how risks are managed. EVIDENCE: Care plans seen show that service users are fully involved with their content. In discussion with the service users and staff the inspector was able to establish that there is good communication between all parties and that plans are reviewed as part of an ongoing reflection of the work practices at the home. Risk assessments are completed but require development. Individual service user files need to contain both general and specific risk assessments. Risk assessment completed centrally and kept at the main office need to be included on files within the home. Issues relating to the safety of one service user and the balances needed to maintain and develop independence against the risk to their well-being were discussed. The registered manager is to consider strategies to negotiate an Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 11 agreement with the service user on the basis of their responsibility to keep people informed of their whereabouts and the homes in supporting them to be as independent as possible. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14,15,16 Practices within the home ensure that service users have a choice of leisure activities and are supported to maintain appropriate relationships. EVIDENCE: Service users were happy to share with the inspector their experiences about their daily life within the home. It was noted that service users were encouraged to choose individual activities, as well as taking opportunities to be part of organised group events. Service users had recently been on holiday that they had chosen with others living in the group of homes managed by Mr & Mrs Hamilton. It was acknowledge that if a service chooses not to attend an event support would be offered for an alternative. Service users were encouraged to invite friends and relatives to their home. If necessary support to understand the issues arising from relationships was given. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 13 Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Practices support service users to be positive in maintaining their health care needs. EVIDENCE: All service users are supported to register with a local GP and have the necessary support to access local primary health care services. Service users health care needs were considered when new flooring was fitted at the home. Laminate flooring has reduced the amount of house dust and has improved the environment for individuals who are asthmatic. Care plans detail individual health care needs and the staff ensure that service users needs are monitored. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The homes complaints procedure protects service users rights to having their views heard. EVIDENCE: There have been no complaints made since the last inspection. In discussion with service users it was evident that they were confident in airing their views and knew whom to approach. Details of the complaints procedure are contained within the service users guide and available within the home. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,30 The homes environment is fit for purpose and is maintained to a good standard. EVIDENCE: The home was found to be clean and tidy with no unpleasant odours. Service users were happy to show the inspector their rooms and discussed how they had chosen their décor. One service user asked if they could have their room redecorated and this was taken up with the registered provider who informed the inspector that the room had been decorated as the service users moved into the home a few months earlier. The Registered Manager needs to discuss and make clear with service users the time scales in which decorations would be renewed and have this clearly stated in the service users guide. The flooring at the home has recently been renewed and it was clear that medical conditions of service users had been considered. (See standard 19) Service users had personalised their own rooms and several had installed their own media/music equipment that enabled them to have choices of activities. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 17 The main lounge/dining room was fitted with suitable furniture with the usual media equipment for group viewing/listening. The kitchen was well equipped and service users joined in the preparation of meals. To the rear of them property there was outside space where service users could sit and relax. This area also provides access to another building that is used as the providers’ main office. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36 Robust recruitment & selection practices protect service users. EVIDENCE: The home has the benefit of a low turnover in staffing. A newly appointed member of staff had been recruited using the home selection policies. Required employment checks have been completed on all staff working at the home with records being kept at the office on the same site. The inspector was able to confirm with the new staff member that they had undertaken a full and robust selection process. In discussion with the registered manager and other staff it was evident that they all had a good knowledge of service users needs. The staff team meet on a regular basis to share information. The registered manager was advised to maintain records of these meetings. This would demonstrate that group supervisions had taken place. Individual supervision to not take place and the manager needs to consider how staff are supported with issues that they may not feel comfortable in bringing to a larger staff meeting and that have a bearing on their work. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 19 Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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 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) 38,42 The homes management enables service users to develop self confidence in being involved within the home and its development. Health and safety checks do not fully ensure service user safety. EVIDENCE: The registered managers style of leadership is reflected in the way service users and staff feel able to discuss issues freely. The regular meeting with staff ensures that important issues are brought to their attention. Service users expressed that they would feel confident in talking with the manager and have good relationships with them to date. In observation of practice it was evident that staff were working consistently to empower service users to be involved within the day to day running of the home. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 21 The home is well maintained and the inspector was able to see that regular testing of electrical equipment and heating was ongoing. The inspector noted that hot water tap do not have temperature controls. The registered manager needs to take advice from the environmental health officer and undertake risk assessments for individual service users to ensure safety. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x x x 3 Standard No 11 12 13 14 15 16 17 x x x 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Agape Annexe Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 23 No 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 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. 2. 3. Refer to Standard 9 36 42 Good Practice Recommendations The manager needs to review how risk assessments are undertaken and ensure that all risks have been identified for individuals and a record is kept on their files. The manager needs to develop a system to undertake supervisions and have appropriate records in place. It was agreed that advice would be sought from the environmental health officer in relation to the control of hot water temperatures. Risk assessments on the use of hot water need to be in place for all service users.. Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Agape Annexe C51 C08 S12678 Agape Annexe V247238 020905 stage 4.doc Version 1.40 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!