Inspection on 21/09/05 for Agape House

This inspection was carried out on 21st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 House 29/05/09

Agape House 28/10/08

Agape House 05/08/08

Agape House 12/02/08

Agape House 07/06/06

Agape House 15/05/06

Agape House 15/04/05

Agape House 01/02/05

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

CARE HOMES FOR OLDER PEOPLE Agape House Agape House 45 Maidstone Road Chatham KENT ME4 6DG Lead Inspector Lucy Ansell Announced Inspection 21st September 2005 09:00 X10015.doc Version 1.40 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 House DS0000061836.V251538.R01.S.doc Version 5.0 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 Older People. 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 House DS0000061836.V251538.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Agape House Address Agape House 45 Maidstone Road Chatham KENT ME4 6DG 01634 841002 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) Nanthini Paramasivam Thiyagarajah Paramasivam Vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th April 2005 Brief Description of the Service: Agape House is a detached Victorian home providing accommodation on two floors, there is a passenger lift to the first floor. Agape provides care for 19 older persons. There are a variety of aids and adaptations around the home, which enable more independence for the residents. The home has 16 bedrooms. The home is situated in a residential area less than a mile from Chatham railway station and town centre. The home is located on a main bus route and within walking distance of shops and a Post Office. The home has attractive front and rear gardens with seating. Agape is a Christian based home and has regular contact with local clergy. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection took place on 19th September 2005 by one inspector Lucy Ansell. The Inspector agreed and explained the inspection process with the Registered Owner. Documentation and records were read, including care plans. Time was spent reviewing a sample of written policies and procedures, looking at care plans and records kept within the home. A tour of premises was undertaken. The focus of the inspection was to assess the Home in accordance to the National Minimum Standards for older persons and to seek resident’s and representatives views of the home. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. Some Standards were not inspected in full and the last report should be read in conjunction to obtain a full picture. What the service does well: What has improved since the last inspection? Progress has been made in addressing staffing shortages and as a result four new care staff have been employed. Staff morale on the day appeared to be high with a good feeling in the home, which was noticeable. The residents of the home consider the level of activities that the home is currently offering about right now, with bingo and quizzes and more outside entertainment coming in. The paperwork is kept securely and up to date and a new staff office has been created on the first floor. The bathrooms are cleared of personal toiletries and laundry holders are not stored in them blocking access to the room. The laundry room has been painted and new flooring put down. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 6 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. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 The home’s Statement of Purpose and Service User guide do not contain the required information for residents and families to make an informed decision about moving into the home. Resident’s benefit from the home’s system of pre assessment, which ensures that the home is able to meet their needs. EVIDENCE: The home has worked at improving the statement of purpose to reflect the new owner’s vision of how the home will be run. The services and facilities offered by the home need to be added to ensure a complete picture was seen. The service users guide also lacks key information and the manager can find all the information required, as listed under standard one. The home now has its statement of purpose and service users guide as two separate formats. These can now be used for their correct purpose of informing residents prior to choosing a home and as a source of reference after moving into the home. Residents are admitted following a full assessment by the homes owner and head of care, which also forms part of the overall, care plan. The home needs Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 9 to be careful of always having dates on all documentation, care manager details and the place where the interview was conducted. A good practice recommendation was made to keep a record so as to provide evidence of trial visits being offered, and when relatives came for an initial visit whether service users were also invited. The home does not offer intermediate care. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 The residents do not benefit from having current care plans in which they have had an involvement in to ensure that all care needs are fully met. The residents can be confident that the home is largely promoting and maintaining service users health needs and that they will be with respect. EVIDENCE: The sampled files indicated that the care plans are still based on the original assessments done at admission. It was explained to the owner that care plans seen were out of date for reviews and lacking in detail. The assessment should be renewed each six months and a new care plan written. No evidence was seen of the service users and/or representative involvement in the formation of any plans. The care plans in some cases have been reviewed monthly, but it was found that care plans did not truly reflect the situation the resident now faces, with regards mobility for example. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 11 The daily record did not show the time of the care and events happen during the day to the service user. They also lacked detail of how the staff are promoting independence for example. Often the daily records did not cross reference to the care plans and some events were not recorded. The home promotes and maintains residents health through supporting and facilitating medical appointments as required. However some health care needs are not being fully identified because the needs assessments are out of date. The plans of care did not always show the require intervention to protect the resident’s from pressure sores or promote tissue viability. The interventions for preventing falls were found in most cases not to have been completed. The risk assessments on the care plans looked at were also found not to have been completed. The staffs on duty were observed indirectly throughout the inspection, seen to interact in a positive and respectful manner with residents. Residents gave positive feedback during the inspection about the approach of the staff team, comments included “ the girls are caring and helpful” and “they are lovely”. Residents are consulted regarding their wishes concerning terminal care and arrangements after death. The home has clear instructions on the care plans seen and care and support is provided for relatives after bereavement. Visitors are made welcome at any time and a private visitors room is made available with refreshments as required. This was evidenced during the inspection and on speaking to a relative. They stated, “They visited most days they were always made welcome by the staff and her mum has had no problems with the home that she was aware of”. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11-15 Residents benefit from having access to a selection of activities, however these could vary more in choice and skill level so meeting the diverse needs of all. The residents can be confident that they will be helped to exercise choice and control over their lives. Residents benefit from the provision of home cooked meals using fresh ingredients. EVIDENCE: There are a variety of activities in place for residents including games, bingo, and quizzes and arts and crafts group. However the resident’s would benefit from more games and activities, which include using different senses and areas of skill. Other activities also include music and movement, physiotherapy, reminiscence work, sing-along and monthly film shows etc. The home could look into accessing specialist organisations that cater for special recreational activities. Outside entertainers or singer also visits the home, and the church visits frequently. It was evidenced that outings on a regular basis would be appreciated by several of the resident’s. The home needs to keep good records that show all service users are being motivated on a regular basis. A number of residents spoken to in the home commented on the food said how good it was and that they welcomed the daily choices offered. Residents were observed during meal- time and lots of fresh vegetables and choice and variety Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 13 was offered. One resident stated “ the food was very good and sometimes too much”. The cook believes in making things from scratch and cakes are made most days, as are puddings. One resident is a vegetarian and she feels she is well catered for. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The resident’s benefit from having access to a clear complaints procedure. Whilst residents are largely protected from any abuse their safety might be compromised by lack of staff training with regard to Adult Protection. EVIDENCE: The home has a clear step-by-step procedure that meets the requirement of the regulations. The complaints procedure was displayed within the home and evidence was seen of it included in the statement of purpose and service user guide. The home has received no complaints since the last inspection. The home does not ensure the residents are safeguarded from any abuse, neglect or harm by the home’s policies as they need updating. The owner gives training for all staff at induction, then they are advised to attend courses in the Local Authorities protocols on Adult Protection. The home was advised to have a copy of the Local Authority’s updated policy on file. Staffs when questioned were not able to give comprehensive replies to what they would do in case of suspected harm to a resident. The home has a whistle blowing policy. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 Residents live in a safe, well-maintained, clean and homely environment. The residents benefit from being surrounded by his or her own possessions. EVIDENCE: Most residents occupy spacious single bedrooms, two of the rooms are shared, one by a married couple and one by two friends. The majority of rooms have ensuite toilet facilities and where these are not included a suitable bathroom is located nearby. The home has sufficient toilet and bathroom facilities for the number of service users. The home has three communal spaces, one of which is a quiet room, another for viewing the television and a lounge attached to the conservatory, which is now a large dining area. All the resident’s rooms that were looked at were very homely and had personal possessions in them that added to the room’s character. The rooms all contained the required furnishing and assured the resident’s privacy. There is a privacy screen in the double room. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 16 The premises’ cleaning is to a high standard and all areas were free from offensive odours. The home has systems in place to control the spread of infection, and staff was seen wearing protective clothing. The laundry room downstairs has had a new floor put in and been painted. The home has policies on infection control and safe handling. The home does not have a sluice machine and a requirement is made for the home to purchase one. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Residents’ needs are met by sufficient staff however the staff team need to develop their knowledge and skills so as to provide a competent and skilled workforce, to ensure residents are in safe hands. EVIDENCE: The home has employed 4 new staff and now has a full staff rota of 23. This is managed for each shift with the manager or a senior on duty then 3 care staff working on the floor for the morning shift and 2 care staff working on the floor for the afternoon shift with 2 waking night staff. The home needs to produce a training matrix so they can see at a glance what training is required. The home is committed to training however there are significant gaps still. The home needs to send all staff on Adult protection training, and new staff need to complete the five basic training core skills and also dementia care. The home does invest in good induction training and also has produced a homes induction booklet. Discussion was made about the home training a responsible person to become a trainer for the home in the induction process. The home has also enrolled four carers on to NVQ 2. The home has five staff who have completed their NVQ’s, and four who are just finishing. The home is to be commended on excellent staff files which contains all required info. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, 37 The home is run in the best interest of the residents. The home’s policies, procedures and management largely safeguard the residents’ rights and best interests. Staff are appropriately supervised and residents can be confident that their finances are safeguarded. EVIDENCE: The manager has undertaken lots of training since taking over the home. She is now a trainer in Moving and Handling, Food Hygiene and Health and Safety. Her past experience as a registered nurse enables her to meet the needs of the residents and she has completed her formal management training that is the R.M.A. and now has the care units to be assessed. Her Fit Person Interview at the Commission for Social Care Inspection is booked for October 2005. The home has a quality assurance monitoring form and intends to use it next week on the coffee morning of the owners first year. She was advised to canvas all professional contacts as well as friends and family of the residents. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 19 The owner will need to look at ways of making the results and any outcomes available for public consumption. The home does not hold any resident’s monies and bills the family for any monthly expenses occurred. The manager and the head of care have started staff supervision and these will be at least six times a year. The supervision in the home covers aspects of practice, philosophy of care and training needs. The home now has a dedicated room to keep all residents care plans and a quiet space for staff to go and write them up. The records for the home need to be regularly maintained to ensure they are all up to date. The home does keep all records securely in locked rooms or filing cupboards. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x 3 x 2 STAFFING Standard No Score 27 3 28 x 29 4 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 3 2 x Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 21 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. 9 Standard OP37 Regulation 24(1) Requirement Timescale for action 30/12/05 8 OP30 18(1) 7 OP26 23(2)(k) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. The registered person ensures 30/12/05 that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The home does not have a sluice 30/03/06 machine and a requirement is made for the home to purchase one. The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, DS0000061836.V251538.R01.S.doc 6 OP18 13(6) 30/12/05 Agape House Version 5.0 Page 22 5 OP12 16(2) 4 OP8 15(1) 3 OP7 12(2) 2 OP3 14(1) 1 OP1 4 (1) in accordance with written policies. The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. This is reviewed every month, and includes risk assessment particularly prevention of falls. New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, with all information required on assessment. The statement of purpose clearly sets out services and facilities, and terms and conditions of the home; and a summary of this information appears in the home’s service user’s guide. 30/12/05 30/12/05 30/12/05 30/12/05 30/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2 Refer to Standard OP12 Good Practice Recommendations A good practice recommendation is made for the home to ensure it keeps good records that show all service users DS0000061836.V251538.R01.S.doc Version 5.0 Page 23 Agape House 1 OP3 are being motivated on a regular basis. A good practice recommendation was made to provide evidence of trial visits being offered and when relatives came for an initial visit whether service users were also invited. Agape House DS0000061836.V251538.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 House DS0000061836.V251538.R01.S.doc Version 5.0 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. 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