Inspection on 29/05/09 for Agape House

This inspection was carried out on 29th May 2009.

CQC found this care home to be providing an Adequate service.

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 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 21/09/05

Agape House 15/04/05

Agape House 01/02/05

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Agape House 45 Maidstone Road Chatham Kent ME4 6DG Lead Inspector Sue McGrath Unannounced Inspection 29th May 2009 09:30 DS0000061836.V374357.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Agape House Address 45 Maidstone Road Chatham Kent ME4 6DG 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) 01634 841002 Mrs Nanthini Paramasivam Mr Thiyagarajah Paramasivam Manager post vacant Care Home 20 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 20. Date of last inspection 5th February 2009 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 20 older persons. It currently uses four beds for service users with a diagnosis of dementia. 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 front and rear gardens with seating. The fees charged by the service range from £385 to £450 per week. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Unannounced inspection that took place in accordance with the Inspecting for Better Lives (IBL) process. Key inspections are aimed at making sure that the individual services are meeting the standards and regulations and that the outcomes are promoting the best interests of the people living in the home. The actual site visit was carried out by 2 inspectors over the course of 1 day. We (the Commission) spent time touring the building, talking to people living in the home and relatives. We also spoke to the manager and staff and reviewed a selection of assessments, care plans, medication records, menus, staff files and other relevant documents. Prior to our visit an Annual Quality Assurance Assessment (AQAA) had been sent to us. The AQAA is a self-assessment, required by law. This assessment focuses on how the service considers they are meeting the outcomes of the people using the service and where it feels it can make improvements. It also provides statistical information about the service. Information from the AQAA has been used in this report where appropriate. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Care Quality Commission (CQC) to be able to make an informed decision about each outcome area. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: The home provides comfortable lounges and dining areas for the people who live there. Most people say they feel well cared for and all say the staff are kind and considerate. There were mixed reviews on the quality of the food and not all agreed they had a choice at meal times. There have been some improvements in care planning and people now benefit from having person centred plans in place. Some people confirmed they had been involved with the new care plans. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 6 Visitors spoken with on the day said they were always made welcomed and that there were no restrictions on visiting times. What has improved since the last inspection? What they could do better: Another new manager has been appointed and the process of registration has begun. This must be completed as soon as possible. There are concerns over the conditions of some of the furniture in the bedrooms. The home must carry out urgent risk assessments with particular regards to the bedside cabinets. Any furniture identified as high risk must be replaced. An environmental risk assessment must be carried out by a person qualified to do so and an action plan developed to identify how any recommendations made are to be implemented. The hot water system must be sufficient to ensure all areas of the home have access to sufficient hot water at all times. The medication room and equipment must be kept clean at all times. The Gas Safety Certificate must be renewed. The provider must review the amount of domestic and ancillary staff she employs to ensure care staff can fully discharge their care duties. The call system must be reviewed and updated as necessary. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 8 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.V374357.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with the information they need to make an informed choice about moving into the home. EVIDENCE: The Registered Provider has reviewed the home’s Statement of Purpose and Service User Guide as required from previous inspections. The statement of purpose now complies with Schedule One of the Care Homes Regulations 2001. These documents should continue to be reviewed on a regular basis to ensure that they continue to give accurate and up to date information regarding the service. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 10 The Registered Provider confirmed that the home had not admitted any new service users since the last inspection. However, the new manager assured the inspector a full assessment would be undertaken by the home and that a joint assessment would be sought from Social Services if they funded the prospective service user. The Registered Provider again confirmed they had developed a new assessment procedure. This will be assessed in full at the next inspection. The home does not offer intermediate care. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from having clear care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Health needs are met and people benefit from having full access to all professional health care services as required. EVIDENCE: The registered provider confirmed all of the people who lived in the home had new care plans that were drawn up with each individual or their representative where possible. Six care plans were viewed and were seen to be person centred and gave clear instruction to staff as how to best meet the individual needs of each person. Some areas of the care plans require further development work and the new manager was aware of some of these areas. The care plans for people with Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 12 dementia were more person centred than at the last inspection but these also need further development work. Staff spoken with were familiar with the plans contents and evidence was seen that all staff had received training on the new formats. The plans now contained nutritional screening as required from the last statutory notice, however, the person completing the assessment failed to include medical conditions that could impact on the persons nutritional status. An appropriate system was now in place to identify any changes. Moving and handling assessment where in place, but the risk assessment section these failed to identify potential risks and record appropriate actions to take. The new manager said she was aware that these could be improved and was planning to replace the assessment with another format. The written instructions given to staff for moving and handling support were clear and detailed. Other areas in need of improvement were identified as risk assessments and end of life care. Evidence was seen that the care plans were reviewed on a monthly basis. This was discussed with one member of staff who confirmed she involved the person where possible with the review. Evidence seen in the care plans confirmed that health care needs were met and that advice was sought from Doctors, District Nurses and other professionals as required. Written positive feed back was seen from both the local GP and the Community Nurses in the homes recent Quality Assurance procedure. Medication was again viewed and again some concerns were raised. The drugs trolley and the medication basket for holding the medication pots were dirty. The basket was made of a material that could not be cleaned thoroughly. During the medication round there was nowhere to put dirty pots when used. There was nowhere for staff to wash their hands prior to administration, so a liquid gel was used. Some discrepancies were noted in the amount of liquid medication for one client. A bottle of liquid medication was found to be very sticky and the label was damaged from spills of medicines, this left service user name obscured and label illegible. The medication room and trolley needs to be thoroughly cleaned and action taken to ensure medication is stored correctly. A sink should be fitted so that hands and equipment can be kept clean. Four care staff that administered medication had completed an in depth ASET ‘safe administration of medication’ course and 6 were currently undertaking the said course. 8 staff had completed the local Pharmacists course. Records confirmed that staff who administer medication are regularly assessed to ensure they remain competent. Evidence was also seen that senior staff regularly audits the medication records. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 13 Most of the staff were seen to be respectful to the residents and to offer choices where possible. However some examples of poor practise were seen and the manager is strongly advised to ensure these practising are not allowed to continue. This was discussed with the registered provider and the manager on the day The people who lived in the home said they were mainly happy and that staff were kind and polite to them. One person did say that sometimes she has to wait for staff to answer her call bell and then she is told to wait and staff sometimes do not return and she finds this frustrating. Other people said the call bells were answered fairly quickly and that staff were always helpful. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. People who live in the home do not always receive a wholesome appealing balanced diet. EVIDENCE: People who lived in the home confirmed the daily routines remained fairly flexible and they were happy with the level of activities on offer. Some said the choices of activities had improved slightly but others said they remained bored at times. Several said they would like some outside activities. The home has employed a student to arrange some activities for fours hours a week over two days. Exercises are now done weekly instead of monthly. The local church attends the home on a regular basis to offer pastoral support for those who require it. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 15 Several visitors were spoken with and all confirmed that they could visit at any time and were always made welcomed. The home has three lounges so people who live there can use one of these if they wish to entertain privately. The kitchen was viewed and some concerns were raised over the choices shown on the menu. The day’s menu was cod and chips, fish fingers and chips or fishcakes. At least one person told the inspector she did not like fish. At dinner time it was noted that she had to wait a long time for her meal of an omelette. Out of the other residents, two had cod and chips, 2 had smoked haddock and chips and the rest had 2 fish fingers and chips. No fresh vegetables were offered, only mushy peas and baked beans. There was little evidence in the store room of fresh vegetables or fruit. Some of the meat in the freezer was not labelled or had been separated and had freezer burn. A piece of meat had been taken out of the freezer for the following day’s meal that was not labelled and it was impossible to say what it was. The menu stated the following day’s meal should have been steak and kidney pie or lamb chops. There were no lamb chops in the freezer. The inspector asked for some scales to weigh the meat. The kitchen scales were found in a drawer and were very dirty. The meat including its large plastic bowl weighed 1370g. This was to feed 17 people. The provider said she had planned to ask night staff to defrost and clean the chest freezer situated in the basement. She was advised to consider carefully about allocating more domestic duties to night staff on grounds of their health and safety but also the welfare of the service users. The provider was asked if the call bells sounded and could be heard in the basement, she replied they could not be heard. The menu did not correspond with what food was being offered to service users each day. The menu was a two week menu, and did not change with the seasons. This needs to be addressed urgently. Not all of the opened food found in the fridge was labeled or dated. The cook does not start work until 09:30 each morning; this means that care staff have to prepare breakfast. They also have to prepare the teas. This means they are not working as carers during this time. The provider must ensure there are sufficient cook/domestic staff on duty to ensure care staff are able to care for the residents at all times. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are protected by a robust complaints system and residents and relatives feel their views are listened to and acted upon. The home has robust adult protection policies and procedures to protect the people in the home. EVIDENCE: The provider stated that the home ensures the residents are safeguarded from any abuse, neglect or harm by having a policy for the home, as well as the Local Authority Guidelines. The new manager was aware of the complaints procedure and stated that she would expect any issues to be dealt with initially by senior staff. If a resolution could not be found then the formal complaints procedure would be used. The AQAA confirmed the home had received four complaints in the last year. These were now recorded. Visitors spoken with confirmed that although they knew how to complain they had not needed to. One safeguarding Adult Alert had been raised and closed by Social Services. The home co-operated fully with this process. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 17 The provider confirmed that the home has adopted Kent and Medway’s Adult Protection Policy and Procedure and records indicated that all staff had received training in Adult Protection. Discussion with staff confirmed they had a good understanding of Adult Protection. All staff had received training in Adult Protection. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the majority of the bedrooms are homely and comfortable but not all have suitable or safe furniture. EVIDENCE: During the inspection we looked at eight of the bedroom, a bathroom, toilets, sluice room, laundry and lounges. The kitchen was also viewed. The provider said that weekly tours were undertaken by senior staff to ensure the room were safe and up to standard, however we identified concerns in the majority of the bedrooms with regards to poor quality and damaged furniture, dirty and stained armchairs and poor odours management. In some shared Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 19 bedrooms there was insufficient space and furniture to meet the needs of two people sharing the room. Although there were environmental risk assessments completed they were generic and not individual to each area of the Home, they failed to clearly identify the potential risk and what action was being taken. The provider will be required to carry out a robust environmental risk assessment, undertaken by a person who is qualified to do so. An action plan will need to be drawn up to identify how the provider intends to manage the outcome. It will be required that unsafe furniture is replaced urgently. Some flooring will need to be replaced. The last report identified a lack of sufficient domestic staff and this has not been addressed. The home currently employs two domestics for a total of thirty hours per week. Evidence was found that this is insufficient for a home of this size and layout. The bathroom on the upper floor did not have an adequate water supply to the bath or shower. The room had recently been redecorated but the call bell was not working. Staff said they rarely use this room and most of the bathing is carried out downstairs. However, the home cannot rely on only one bathroom for up 20 people and this room must be made fully operational. The sluice room was fully operational but here was no liquid soap in the dispenser and no clinical waste bin. Several of the toilets soap dispensers were also empty. There were concerns raised with the registered provider and new manager regarding the poor infection control practices observed during the inspection. Evidence was seen that the call bell system was now monitored regularly, but there were still some concerns. The alarm system for alerting staff that side doors had been opened did not appear to operate fully. We opened the outer doors in the corridors and the alarm did not sound. This is a concern as in the last year two people have left the home unescorted and staff had to search for them. As this is a home for people with dementia this needs to be addressed. The provider will need to address the immediate problem urgently and then consider whether the call system is adequate, as it also does not alert staff when they are working in the laundry and this could have serious consequences, particularly at night. The provider did have a maintenance plan but this was inadequate and did not clearly identify any major environmental planning. The plan identified that bedrooms were due to be decorated in 2011 and then only four a year. It did not identify any replacement of carpets or furniture. There were no plans for maintenance of the roof, plumbing, windows or call system. There was no mention of any maintenance of the thermostatic Mixer Valves. It will be a Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 20 requirement that a robust environmental plan is develop and sent to the Commission. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in the home benefit from being cared for by staff who have an understanding of their needs. People are protected by good recruitment procedures. The care staff ability to fulfil their role as carers is impacted by the need to undertake domestic duties. EVIDENCE: Evidence seen in the staff rotas confirmed that the home has three staff working the morning shift, 2-3 the afternoons and two waking nights. The main concern was the low number of domestic and ancillary hours in the home. The home does not have a dedicated laundry person and this means that care staff have to complete the laundry tasks. They also have to prepare the breakfast and cook the teas. Night care staff are expected to do the ironing in the basement, whilst the care staff undertake domestic duties they are no longer able to fulfil their role as carer. It will be a requirement that the provider evaluates the level of ancillary staff and ensures care staff are able to complete their care duties. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 22 Three staff files were viewed and were found to contain all the information required by regulation. A training matrix has been produced by the new manager which clearly recorded all completed training and when the training needed to be renewed. It identified that staff were well trained. The AQAA identified that of the sixteen permanent care workers, nine had completed NVQ level two or above. One of the cooks had also achieved NVQ 2. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The ethos and management of the home have started to improve. EVIDENCE: The home has had three new managers within the last ten months, and the provider is hopeful the current manager will stay and register with the Commission. The provider said she had started the registration process. The new manager had a background in care, was supported by qualifications and said she is confident she could work with the provider in improving the Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 24 home. The new manager said she has not been allocated a budget but makes requests to the registered provider. At the last inspection we requested copies of the business plan and financial accounts. These have now been received from the home. The business plan was basic did not give details of how the aims were to be achieved. This plan now needs to be developed and put into practise. The accounts were for the previous year (2007) and the provider agreed to submit 2008 accounts. The provider has undertaken a quality assurance exercise including questionnaires for the people who live in the home, staff, visiting GPs, and community nurses. Some of the questionnaires were viewed and all gave positive feed back. Also weekly questionnaire for the people who live there were viewed. The manager was unaware that the provider had completed a report and an action plan due to only being in post for three weeks. The provider contacted the inspector the following day and sent a copy of the report and action plan. Evidence was seen in some staff files and the staff on duty confirmed that supervision is starting to become a regular event. The manager stated that is was her intention to start annual staff appraisals in the near future. The registered provider confirmed that she does not hold monies on behalf of the people who live in the home and normally pays for the extras, such as hairdressing, chiropody and newspaper etc and then invoices the family direct. The maintenance and service paperwork was viewed and was mostly up to date. The Gas Safety Certificate had expired and needed to be completed. The hoist was last serviced in January 2009. The paperwork for the fire system including maintenance and fire drills was muddled and scattered over several files. The provider is strongly advised to manage this is a more structured way. As mentioned earlier in the report the environmental risk assessments were out of date and very basic and a requirement has been made for these to be updated. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 25 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X X X 2 2 Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 26 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 OP15 Regulation 16 Requirement The registered provider shall having regard to the size of the care home and the number and needs of the service users, provide, in adequate quantities, suitable wholesome and nutritious food which is varied and properly, labelled, stored and prepared. In that menus are reviewed to offer service users choice and seasonal variety and any changes to the menu are recorded. The service users must be given the menu to enable them to make true choices. The registered provider shall having regard to the size of the care home and the number and needs of the service users ensure that service users live in a safe, well maintained environment, In that a programme of routine maintenance and renewal of fabric and decoration of the premises is produced and implemented with records kept. The registered provider shall DS0000061836.V374357.R01.S.doc Timescale for action 31/07/09 2 OP19 39 31/07/09 3 OP22 16 31/07/09 Page 27 Agape House Version 5.2 4 OP19 23 5 OP21 23 6 OP31 9 7 OP27 18 8 OP26 13 having regard to the size of the care home and the number and needs of the service users provide in rooms occupied by service users adequate furniture, bedding and other furnishings. In that bedroom furniture is assessed for safety and quality The registered person shall having regard to the number and needs of the service users ensure that the premises to be used as a care home are of sound construction and kept in a good state of repair. In that the door closure on the door to the laundry room is replaced to prevent it slamming shut. The registered person shall having regard to the number and needs of the service users ensure that the premises to be used as a care home are of sound construction and kept in a good state of repair. In that hot water is permanently supplied to all bathrooms. The registered person shall appoint an individual to manage the home and ensure they are registered with the Commission. The registered person shall having regard to the number of and needs of the service users, required to review the numbers of ancillary staff hours needed and review the roles and responsibilities of the care staff in relation to the domestic duties they undertake. In that the care staff are free to provide care to service users at all times. The registered provider is required to review the infection control practices and procedures within the Home and take DS0000061836.V374357.R01.S.doc 31/07/09 31/07/09 31/07/09 31/07/09 31/07/09 Agape House Version 5.2 Page 28 9 OP38 13 appropriate action to ensure the Home complies with current protocols and guidance. Therefore ensuring service users are protected by adhering to infection control procedures. The registered provider must undertake, complete and record environmental risk assessments that truly identify potential risks and what action is required to minimise the risk. This is to protect service users from potential harm and danger. 31/07/09 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 Refer to Standard OP19 OP8 Good Practice Recommendations It is recommended that consideration is given to replacing the call bell system and to include the laundry area. That all risk assessments relating to service users are reviewed and correctly completed, to record the risk and the appropriate action staff should take. This should include, manual handling, falls and nutrition. Agape House DS0000061836.V374357.R01.S.doc Version 5.2 Page 29 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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