Inspection on 02/09/05 for Agape Lodge

This inspection was carried out on 2nd September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Agape Lodge 16/02/09

Agape Lodge 06/03/07

Agape Lodge 30/01/06

Agape Lodge 07/01/05

Agape Lodge 29/04/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Agape Lodge 155 Kings Street Kettering Northants NN16 8QR Lead Inspector Judith Roan Unannounced 2 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Agape Lodge Address 155 Kings Street Kettering Northants NN16 8QR 01536 510808 01536 390608 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Hamilton Mrs Julia Hamilton Care Home 3 x3 Category(ies) of MD Mental Disorder registration, with number of places Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The Home will limit its services to the following service user categories: No person falling within the category Mental Disorder (MD) can be admitted where there are already 3 persons of category MD in the Home. No person under the age of 18 years or of/over the age of 65 years must be admitted to the home. The total number of service users in the Home must not exceed 3. Date of last inspection 7-Jan-2005 Brief Description of the Service: This is a 3 bedded, privately owned home situated in Kettering, within walking distance of the town centre and 2 other small homes in the same group. Service users are actively involved in the wider community, and are under 65 years of age. Nursing care is not provided. Accommodation comprises of a lounge, kitchen/dining room, 3 bedrooms, bathroom with shower, and toilet. The Registered Providers are active participants in the day to day management of the home. The home’s philosophy is that staff and families will support service users where necessary, so that the individual’s achievable level of independence can be maintained. It is accepted that more support for service users may be required than in the 2 sister homes. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 1 residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. During the inspection views of other service user living at the home were sort. The inspection took place during the evening over a period of 2.5 hours and was carried out on an unannounced basis. What the service does well: What has improved since the last inspection? What they could do better: 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 Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Practices within the home ensure that service users needs are assessed. EVIDENCE: The inspector tracked one service user during this inspection. The case file demonstrates that a full assessment was undertaken prior to the admission of the service user. There was evidence that a risk assessment had been completed in relation to the service users potential to self-harm. General risk assessments’ are completed and held at the offices situated in Havelock Street. In discussion with the registered manager it was agreed that risk assessments would be kept on individual files. The service user spoken with was aware that an assessment had been completed and was fully involved in the process. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,8,9 Service users can be confident that their assessed needs are recorded and that they will be supported to take risks as part of an agreed person centred plan. EVIDENCE: There is evidence that service users have agreed their plan of care and that these are kept under review with staff at the home and other professionals involved with their care. Service user spoken with confirmed that they met with staff and were consulted about the activities they undertook. Staff supported this view. It was evident from observing practice within the home that service users are given the information to make choices. The homes principals of care stated in their Statement of Purpose are embedded in practice. Service users are fully involved in the running of the home and are supported to make decisions. Risk assessments viewed need to be developed to ensure that the process of how the level of risk is determined and have clear guidelines for staff to actively minimise the risk. In discussion with the inspector the registered manager agreed that both general and specific risk assessments would be placed on individual files. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,17 Service users have access to a range of activities of their choice. The practices at the home enable service users to participate fully in their chosen lifestyle. EVIDENCE: In viewing the case file of the service users chosen for ‘case tracking’ and in discussion with them the staff have provided develop opportunities as part of the agreed plan of care. The service user has a programme of activities that has been developed to meet her planned goal of moving to a more independent setting. The home provides and gives appropriate support for all the service users to access the local amenities that include swimming, local clubs and public houses. Service users have developed friendships with people they meet at the day centres and with others living within the homes in the group. The service users spoke about their recent holiday that they had enjoyed. All services meet on a regular basis to discuss menus, activities and trips out. One service user told the inspector that they cooked their lunch on some days with support from a staff member. The service users also goes shopping for Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 10 the ingredients and this was helping them to be more independent. The service users were happy with meals provided and were encouraged to eat a health and balanced diet. During the week some service users had a cooked meal at the day centre or took a packed lunch. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Service users are supported in the way they choose and given the appropriate support to access health care services when needed. Service users are protected by the practices of administration of medication in the home. EVIDENCE: Service users confirmed that the support they received was their choice and they had the opportunity to discuss this with staff. Service users have access to local health care professionals and monitoring is in place to meet identified health care needs. One service user spoken with was pleased with the improvement in their health and was fully involved with the monitoring. There is evidence in the case recording that links with health care professionals are good and that staff have received training to support the service user in maintaining their emotional health. Staff are knowledgeable on the subject of administration of medication and maintain accurate records. There is good communication between the staff and community nurses in relation to managing medication. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The homes policies, procedures and practices protect service users. EVIDENCE: Service users were able to tell the inspector whom they would speak to if they had a complaint or whether they were unhappy with the way a member of staff supported them. Service users spoken with were satisfied with the service provided and had no cause to complain. The home has clear policies in relation to complaints and abuse awareness. Staff were able to discuss how they would deal with a complaint, concern or a service users disclosing an abuse had taken place. There have been no complaints since the last inspection. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,30 The homes is clean and hygienic and provides service users with a homely environment that is fit for purpose. EVIDENCE: The home that is on two floors was found to be clean, hygenic and well maintained. Service users share a bathroom and have the option of a shower or bath. The home is bright and service users have chosen the decoration and personalised their bedrooms. There is a staff sleep in room at the home and they provide support as required at night. The environment is checked on a regular basis to ensure it is safe. Records of safety checks were inspected by the inspector. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35,36 A consistent staff team that have clear job roles supports service users. The home has recruitment procedures that protect service users. EVIDENCE: The registered manager confirmed that the staff team meet on a regular basis to discuss issues. The manager needs to consider how with no formal supervision structure in place for staff they record individuals concerns, progress and future development needs. In discussion with staff it was evident that they were knowledgeable about the needs of service users and were continually improving their practice in line with current thinking on the needs of people with a learning disability or mental illness. The registered provider and manager are committed to training and provide opportunities for staff to complete required training. Mr & Mrs Hamilton are presently undertaking the Registered Managers award and are supporting others to gain National Vocational Qualifications. A newly appointed staff members records were checked and found to contain the required information. The registered provider was able to confirm that all staff had current Criminal Record Bureau Disclosure certificates. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,41,42 Service users can be assured that the home is managed in their best interests Health and safety is generally promoted. EVIDENCE: In discussion with the homes manager and a staff member the inspector is satisfied that there is a clear structure across the three homes with delegated responsibilities. There are regular meetings between the staff team members where issues are discussed and decisions are made. The home needs to ensure that full records are kept of these meetings. The homes safety checks are undertaken and the inspector was able to see these records at the office in Havelock Street. The provider holds documents that demonstrate that checks have been undertaken on electrical appliances, central heating and fire equipment. Staff training in health and safety has been completed. A new member of staff is presently undertaken their induction and they are booked on recommended health and safety training. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 16 Temperature thermostats do not control hot water taps. The provider was advised that advice from the environmental health officer must be sought. Risk assessments need to be completed on all individuals of the potential risk that hot water poses. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 3 x 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Agape Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 3 2 x C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 9 36 42 Good Practice Recommendations The manager needs to review how risk assessments are undertaken and ensure that all risks have been identified for individuals and a record is kept on their files. The manager needs to develop a system to undertake supervisions and have appropriate records in place. It was agreed that advice would be sought from the environmental health officer in relation to the control of hot water temperatures. Risk assessments on the use of hot water need to be in place for all service users.. Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Agape Lodge C51 C08 S12680 Agape Lodge V247235 020905 stage 4.doc Version 1.40 Page 20 - 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. 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