Inspection on 05/08/08 for Agape House

This inspection was carried out on 5th August 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Agape House 29/05/09

Agape House 28/10/08

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 22/11/2008.

CARE HOMES FOR OLDER PEOPLE Agape House 45 Maidstone Road Chatham Kent ME4 6DG Lead Inspector Sue McGrath Unannounced Inspection 5th August 2008 09:30 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.V367014.R02.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 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.V367014.R02.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.V367014.R02.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 12th February 2008 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 has 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 attractive front and rear gardens with seating. The fees charged by the service range from £380 to £465 per week. Agape House DS0000061836.V367014.R02.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 that the outcomes are promoting the best interests of the people living in the home. The IBL process for a Key inspection involves a pre-inspection assessment of service information obtained from a variety of sources including an annual selfassessment and surveys. It is now a legal requirement for services to complete and return an Annual Quality Assurance Assessment (AQAA). This assessment is aimed at looking at how services are performing and achieving outcomes for people. Homes have twenty-eight days to complete and return the AQAA. The Registered Provider did not return the AQAA in the specified time and a reminder letter had to be sent. 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 Commission for Social Care Inspection (CSCI) to be able to make an informed decision about each outcome area. Further information can be found on the CSCI website with regards to the IBL process including information on KLORA’s and AQAA’s. The actual site visit to the service was carried out over one and a half days by two inspectors. The main focus of the visit was to review any improvements made since the last visit and the well-being of the service users. Time was spent touring the building, talking to people living in the home, talking to staff and reviewing a selection of assessments, service user plans, medication records, menus, staff files and other relevant documents. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The management of the home continues to be poor and this needs to be addressed urgently. Assessments need to be more robust and reflect the actual needs of any prospective service user. Care plans need to reflect the need of the individual and be accurate. They should be drawn up with the resident and or their representative and accurately reflect the assessments and give clear guidance to staff to ensure assessed needs are met. Reviews must be more accurate and reflect any changes in the condition of the service user. They should not be a paper exercise. The home needs to be cleaner and more domestic staff are required. The home must have a robust cleaning schedule in place that is regularly monitored. The home must put in a system so that any maintenance work can be identified and completed. The home must review the call system and ensure it is fully operational at all times. If this cannot be accomplished a new system will need to be fitted. Hot water temperatures need to be monitored to reduce the risk of scalding to the service users. Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 7 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 House DS0000061836.V367014.R02.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.V367014.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 4 and 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prospective residents are not given the full information on the home prior to admission. People who live at this service are put at risk because of lapses in the assessment process and this means they cannot be assured their care needs will be met. EVIDENCE: The registered provider had updated the homes statement of purpose in August 08. There was little mention of the dementia beds and this could cause confusion amongst prospective service users. The document states the home is registered for twenty service users only. Later in the statement there was mention of what extra services were offered for people with dementia such as Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 10 a separate lounge, separate mealtimes and keypad system for internal doors for safety. During the inspection these services where not seen to be offered. The statement also stated that ‘all temperatures in bathrooms and wash hand basins are checked weekly to provide the correct temperature’. This could not be evidenced and the water in several of the bathrooms and bedrooms felt excessively hot. The thermometer available in the bathroom on the upper floor was broken and readings could not be taken. At the last inspection it was highlighted that the home was not assessing new service users adequately and that needs were not being fully met. At this inspection the assessment process was again viewed and still remains a concern. Two new service users had been admitted since the last inspection, both were funded by Social Services. There was no evidence of written assessments from Care Managers. The assessments that were completed by the home were not reflected in the care plans, for example one service user was assessed as ‘independent with no history of falls’ but in the life history it clearly states ‘is trying to get confidence back after falling’. Other assessments say chair bound and others say independent for the same service user. A requirement was made at the last inspection that the registered person must not admit any service user without a thorough and detailed assessment to ensure assessed needs can be met. This has not been met and enforcement action may now be taken. The Registered Provider stated that all prospective service users and their relatives are encouraged to visit the home prior to admission. Agape House DS0000061836.V367014.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who live in the home do not benefit from care plans that identify their current and changing needs and cannot be confident that their health care needs will be fully met. This has the potential to put them at risk. People who live in the home are protected by the home’s procedures for dealing with medication. EVIDENCE: At the last inspection a requirement was made to ensure each resident had a service user plan of care generated from a comprehensive assessment (see Standard 3) and was drawn up with each service user and provided the basis for the care to be delivered. Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 12 The registered provider stated she had personally drawn up new care plans for each resident and that the standard had improved. Four plans were looked at in detail and excerpts looked at from others. There remains a generic approach to care planning that is not person centred and does not reflect individuality and diversity. Therefore this has contributed to people receiving a sub-standard level of care and support in their daily lives and this approach does not meet with either accepted good practice guidelines or National Minimum Standards. The new care plans did not reflect the assessments and gave little guidance to staff as to how to meet the individual care needs. Reviews did not always reflect changes in the service users condition for example, the recording of weights. This appears to have been a paper exercise. Where weight losses were recorded there was no evidence of any action being taken. The reviews for one service user who had lost one stone in four weeks stated ‘No change - appetite very good’. It did not reflect that the service user had lost one stone. Six service users were recorded as having lost between nine pounds and one stone five pounds since March this year. No action had been taken in any of the cases. The Commission has raised a Safeguarding Vulnerable Adults Alert with Social Services. According to the admission assessment for one service user it stated he was mobile when admitted but within a couple of weeks was no longer mobile and was confined to a wheelchair. There was no evidence that this had been noticed or investigated. It appeared to have just been accepted and not commented or acted upon. The basic concept of care planning does not appear to be understood and urgent training and support is needed. The management appears not to understand that when a risk has been identified there must be a plan of action recorded to ensure staff are working towards reducing the risk. Care plans should be drawn up with the service users and or their representative’s involvement where possible and this needs to be clearly indicated on the plans. Person centred planning means discussing the needs of the individual and writing a plan specifically for that person. The care plan must reflect the needs and wishes of the individual. The administration of medication had improved since the last inspection and was managed by the head of care. Medication was signed for and dated upon arrival. The actual administration was observed and was carried out in a safe and professional manner. One area of concern was the PRN medications, as there were no guidelines as to when to actually give the medications. It is advised that guidelines be Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 13 produced for each individual PRN medication. This was discussed with the head of care during the inspection. Another concern raised was staff taking changes in medication over the phone. There must be a robust procedure in place to ensure errors do not occur. Phone messages should only be taken in an emergency and then two members of staff must confirm the change in writing. Written instructions must be sought from the professional making the changes as soon as possible and without delay. Agape House DS0000061836.V367014.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Little consideration is given to supporting people’s individuality or social preferences and staff choose the activities provided. EVIDENCE: Service users confirmed the daily routines remained fairly flexible and they felt free to come and go, as they like. Several commented they were bored and others said they had plenty to do. Some said they missed going out and would like some outings. The home does not have a dedicated activities co-ordinator and staff try to amuse the residents to the best of their abilities. These sessions are often repetitive and not always recorded. The television was on during the morning showing a pop video. Several service users said they did not like this but the Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 15 programme was not changed. They seemed to have little choice over the choice of programme watched. Some care plans recorded family histories but few recorded aspirations and wishes. As at the last inspection the home is not responding to the diverse needs of people and there was little evidence to show that their religious, cultural and social interests are being taken into account in their daily lives. There are some visits from the local Church but these are not as regular as the provider stated. Service users confirmed that their relatives could visit whenever they liked and were always made very welcomed. Most service users said staff were very caring and they felt well looked after, however some said staff could sometimes be abrupt when they asked for assistance. During the inspection staff were mainly seen to be caring and considerate. One member of staff had recently returned from holiday and had bought back some Sangria for the residents to have with their lunch. At other times staff were seen to be very busy and appeared abrupt and rushed. The response from relatives was mixed. Some said they were happy with the care offered and others said they had some reservations. Some commented on how dusty the home seemed and some said the décor had improved recently. Most service users said the food was fairly good although one said the vegetables were often hard and unappetising. The full time cook was on maternity leave and the provider was hoping she would return soon. The home uses agency cooks at the week-ends. The home was unable to produce any records of food, fridge or freezer temperatures. The provider stated ‘the new manager had lost them’. No replacement records had been started. The home is strongly advise to contact the Environmental Health Authority to discuss the new ‘Safer Food Better Business’ initiative for care homes to ensure it had the correct paperwork in place. The home has dedicated menus in place but it was clear these were not always followed and depended on ‘what the night staff got out’. Drinks were available during the day as well as meal times. There was no record of the food taken and again it is recommended that this be addressed to ensure that residents are receiving a balanced diet. Agape House DS0000061836.V367014.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home are protected by policies and procedures for complaints and Safeguarding Adults, but some practises in the home put some residents at risk. 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 home must make this accessible to residents and their representatives, as those who were spoken with were not aware the home had any complaints procedure. One service user stated he has ‘had arguments when making a complaint and does not feel like it is worth it as no body listens’. The provider stated that records were maintained of all verbal complaints. We looked at the complaints book and saw that there had been two recorded complaints since the last inspection and both of these had been acted upon. One person living in the home stated that they had made verbal complaints and ‘there was never anything done about them’. We discussed this and the Registered Provider was reminded of her responsibilities in making sure all complaints were listened to and acted upon. Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 17 The last improvement plan stated the home has a copy of ‘No Secrets’ in the home but the provider was unable to discuss its content and could not find it. The provider is advised to make herself familiar with this document. Staff have received training in Safe Guarding Adults as required from the last inspection. Action has now been taken regarding the shared room that was mentioned n this section at the last inspection. Both service users now have separate rooms. The provider must ensure that in future service users wishes and concerns are listened to and where possible are acted upon. Agape House DS0000061836.V367014.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home need to be improved for the benefit of the people who live there. Maintenance and refurbishment work is reactive rather that proactive. EVIDENCE: At the last inspection a requirement was made that the ‘registered person shall having regard to the number and needs of the service users ensure that the premises to be used as the care home are of a sound construction and kept in a good state of repair externally and internally’. This had been carried forward from the last two reports. The home has been rewired following the last inspection. Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 19 The majority of the bedrooms were viewed and many were found to be dusty and in need of cleaning. The home employs two domestic staff for a total of thirty-three hours per week. This is insufficient for a home of this size and design. The home does not have a cleaning schedule in place and cleaning is not monitored. There are no domestic staff working during the weekends. One bedroom had a broken chair still in use and the flooring in the en-suite was badly puckered, making it a potential trip hazard. On closer examination the toilet pan was found to be leaking and the floor was very wet. It is of serious concern that these issues had not been noticed by anyone working in the home. This concern was also raised at the last inspection. The registered person did arrange for the repair to the toilet and flooring to be completed during the inspection. However, it was difficult to see how the floor could have dried out before the new flooring was fitted. The home must have a procedure in place for staff to identify any environmental issues and a system in place that ensures repairs are carried out promptly and efficiently. One service user was in his room and needed assistance to use the toilet, however the call bell in his room was not working. The inspector had to use the call bell from another room to call for assistance. Staff stated that ‘the bell was working yesterday’. It was unclear how long the service user had been waiting to use the toilet. The registered provider said the battery must have failed. It became apparent during the following conversation that the home does not have a system in place to check the batteries in the call system and that they do fail on a regular basis. The home will be required to risk assess the existing system and if necessary replace with a more reliable system. The bathroom on the upper floor was dusty and had a badly stained and dirty perspex ceiling. There was a multitude of dead insects and water stains behind the perspex ceiling tiles. The bath thermometer was not working and the water felt very hot. The bath had a shower fitted that the registered provider said they did not use. The handyman did clean the ceiling tiles before the end of the inspection but again this should have been done as part of the general maintenance work and not wait until pointed out on an inspection. Water temperatures were checked in other bedrooms and some were very hot and some were cooler. The home does not record water temperatures on a regular basis and relies on the thermostatic mixers valves to work. Not all outlets had these fitted. The home must record water temperatures on a Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 20 regular basis to ensure the safety of its residents. The homes statement of purpose stated the home checks water temperatures weekly. One of the key pads mentioned in the statement of purpose designed for use with the dementia clients was not working correctly. The provider said two of the bedrooms had new carpets fitted and had been decorated. Most were well personalised with photos and personal belongings. The head of care said that twenty new bedspreads had been purchased since the last inspection. The registered provider had purchased a sluice disinfector but this had not been fitted and therefore was not in use. The registered provider said there was a problem with the pipe work and this has caused the delay in fitting the apparatus. The proposed room would be in need of redecoration before it could be used as a sluice room. Agape House DS0000061836.V367014.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a recruitment procedure in place but does not always follow it and this has the potential to put service users at risk. EVIDENCE: A requirement was made at the last inspection that the registered person must ensure that there are sufficient senior staff on duty at all times to ensure the safety of the service users. This was mainly concerning the lack of senior staff working at the weekends. The provider has now reverted to having senior staff but there was some confusion over the necessary qualifications for a senior position. The homes improvement plan stated that senior staff will have a minimum of NVQ level two and a minimum experience of at least two years at a senior level but the provider said the minimum period was three years. When checking the NVQ levels it was noted that not all designated senior staff held NVQ level two. The statement of purpose also confirmed that not all senior staff held NVQ 2. Another requirement from previous reports was the registered person must ensure that at all times there are staff with a recognised first aid certificate on duty to ensure the safety of the service users. The home was advised to Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 22 complete a risk assessment and then take appropriate action to ensure the requirement was met. The improvement plan stated that all staff have now completed first aid training and that a notice would be placed in a prominent place identifying the designated person on duty for each shift. When asked about the notice the provider confirmed ‘it only happened for a couple of days as she forgot to carry on doing it’. The training matrix identified that some first aid training had been completed but it was only a half-day course and staff spoken with said the contents were poor. On the day of the inspection there were no staff with the recognised First Aid at Work course certificate. After the inspection the provider booked four staff onto a First Aid at Work course. The improvement plan states all staff had received accredited training in safe guarding vulnerable adults as required from the last inspection. The home must ensure all new staff be trained in this area. The Provider completed this training. The home does have a training matrix but it was changed several times during the inspection and was difficult to follow. The provider will be required to provide details of staff training so a judgement can be made. The qualifications will need to be evidenced by appropriate certificates. Several staff files were viewed and some gaps in the required information were found. A requirement was made at the last inspection that the registered person must have a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. This requirement has not been met and enforcement action will follow. Agape House DS0000061836.V367014.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not being managed efficiently and there is no leadership, guidance or direction to staff to ensure service users receive consistent quality care. This results in practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: After the last inspection the registered provider stepped down as registered manager and started the procedure to employ another qualified manager. A new manager was appointed on the 1st of June 2008 but resigned at the end of Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 24 July. This means the home is still without a dedicated manager and the registered provider is again managing the home. The registered provider is currently still looking to employ a manager. The home has a legal duty to complete the Annual Quality Assurance Assessment (AQAA). This assessment is aimed at looking at how services are performing and achieving outcomes for people. Homes have twenty-eight days to complete and return the AQAA. The Registered Provider did not return the AQAA in the specified time and a reminder letter had to be sent. When the AQQA was returned the contents were poor. The information given was very limited and it was difficult to make an informed judgement about how well the home was running. There was very little information on equality and diversity, with areas either left blank or noted as N/A. Statements were made with little, or no, evidence to back them up. When spoken with the registered provider was unable to elaborate on equality and diversity issues and is strongly advised to seek training on these issues. In the areas where the home has the opportunity to say what they do well little information was given. Conflicting information regarding staff numbers was given and page seventeen which lists the staff training was missing. After the last inspection the home was obliged to prepare an improvement plan. This was discussed with the provider at this inspection and several areas of the plan had not been followed through or complied with. This means that several of the requirements made at the last inspection have not been complied with and enforcement action is likely to follow Weak management means that staff do not always receive the guidance and support they should and this has an impact on the quality of care provided. The head of care has now returned to working on the floor with the care staff and this has resulted in some improvements, such as better medication administration. The registered provider must ensure that robust monitoring on all aspect of the running of the home is promoted and maintained. The registered provider had started a quality assurance exercise but this has not been fully completed and remains as work in progress. The registered provider confirmed that she does not hold monies on behalf of the residents and normally pays for the extras such as hairdressing, chiropody and newspapers etc and then invoices the families directly. Following the last inspection a requirement was made regarding reviewing the fire evacuations procedure to ensure it complies with good practice guidelines. The home now has an up to date Fire Risk Assessment and new fire signage. A new fire procedure had been prepared in April 08 and evidence was seen that staff had been given copies and had signed to say they understood the new procedure. Thirteen staff underwent fire awareness training. Unfortunately Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 25 staff have not been given the chance to practise the new drill as the last fire drill was dated 09/01/08. Although the statement of purpose indicated that water temperatures were regularly monitored this could not be evidenced on the day and hot water in the home was very hot in some of the bathrooms and bedrooms. The home must ensure robust procedures are put in place to monitor and control hot water to ensure the safety of the service users. Standard 38 of the National Minimum Standards for Older People clearly state, “The health, safety and welfare of service users and staff are promoted and protected”. This includes the management of risks, accidents and incidents. We saw through the records that these were not being managed or risk assessed in line with the regulations or National Minimum Standards. For example in the care plan for one person it had been identified on 1st August 2008 that there had been a fall due to badly fitting shoes. This accident was also recorded in 4 separate other records including the accident book and falls book. None of these recorded how to reduce the risk of future falls and on the day of the visit the person was still wearing the same shoes. Records also showed that they had not attended hospital. This was arranged for the 7th August 2008, which was 6 days after the fall. Further accident and incident records also did not evidence that appropriate action was taken to reduce the risk of falls and accidents. We saw that there had been 26 accidents recorded since 8th May 2008, with no supporting evidence of any action taken to reduce further occurrences. The home is requested to review its health and safety procedures and risk assessments to ensure that all elements of safety are inspected and maintained to ensure that the home meets with the required standards. Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 26 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 1 2 2 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 2 2 X X X X 1 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP30 Regulation 18(1) Requirement The registered person ensures 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. This is carried forward from the last three inspections and remains unmet. This remains unmet again and enforcement work will take place. 2. OP7 15 The registered person shall 05/08/08 ensure that all service user have current risk assessments in place to ensure they are safe and take into account any change of circumstances. In that all service users have manual handling risk assessments and guidance to staff in place. This has been carried forward Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 28 Timescale for action 05/08/08 from the last report and remains unmet. This remains unmet again and enforcement work will take place. 3. OP19 23(1)(a)( b) The registered person shall 05/08/08 having regard to the number and needs of the service users ensure that the premises to be used as the care home are of a sound construction and kept in a good state of repair externally and internally. This has been carried forward from the last two reports and remains unmet. This remains unmet again and enforcement work will take place. 4. OP30 12(1)(a)( b) The registered person must ensure that at all times there are staff with a recognised first aid certificate on duty to ensure the safety of the service users. This has been carried forward from the last report and remains unmet. This remains unmet again and enforcement work will take place. 5. OP27 18(1) The registered person must ensure that there are sufficient senior staff on duty at all times to ensure the safety of the service users. This has been carried forward from the last report and remains unmet. 05/08/08 05/08/08 Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 29 This remains unmet again and enforcement work will take place. 6. OP29 19 The registered person must have a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. This remains unmet again and enforcement work will take place. 7. OP7 15 The registered person must ensure each resident has 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 remains unmet again and enforcement work will take place. 8. OP3 14 The registered person must not admit any service user without a thorough and detailed assessment to ensure assessed needs can be met. This remains unmet again and enforcement work will take place. 9 OP38 13(4) The registered person must have a system in place to ensure water temperatures do not have the potential to be a scalding risk. The registered person must ensure that all hoists are maintained and regularly serviced. The registered person shall DS0000061836.V367014.R02.S.doc 05/08/08 05/08/08 05/08/08 30/09/08 10 OP38 13 (4)(5) 30/09/08 11 OP22 23(2)(n) 30/09/08 Page 30 Agape House Version 5.2 12 OP8 13 OP1 14(1)(a) (2) 17(1)(a) Schedule 3 (3)(m) Schedule 4 (13) 4 ensure that a call system with an accessible alarm facility is provided in every room. The registered person shall undertake nutritional screening on admission and subsequently on a periodic basis, maintain a record of nutrition, including weight gain or loss and take appropriate action as needed. The registered person shall produce and make available to service users an up to date and accurate statement of purpose setting out the aims and objectives, philosophy of care, services and facilities and terms and conditions of the home. 31/08/08 30/09/08 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 OP38 Good Practice Recommendations It is recommended that the home review its health and safety procedures and risk assessments to ensure that all elements of safety are inspected and maintained to ensure that the home meets with the required standards. Agape House DS0000061836.V367014.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 House DS0000061836.V367014.R02.S.doc Version 5.2 Page 32 - 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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