CARE HOME ADULTS 18-65
Agape Lodge 155 Kings Street Kettering Northants NN16 8QR Lead Inspector
Mrs Moira Mosley Unannounced Inspection 30th January 2006 17:00p DS0000012680.V280680.R01.S.doc Version 5.1 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 DS0000012680.V280680.R01.S.doc Version 5.1 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 Adults 18-65. 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. DS0000012680.V280680.R01.S.doc Version 5.1 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 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) Mr Michael Hamilton Mrs Julia Rosemary Hamilton Vacant Care Home 3 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (3) of places DS0000012680.V280680.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 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 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. No person falling within the category Learning Disability (LD) can be admitted where there is already 1 person of category LD in the Home. 2nd September 2005 Date of last inspection 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 homes philosophy is that staff and families will support service users where necessary, so that the individuals 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. DS0000012680.V280680.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a statutory unannounced inspection; the care of the three service users was reviewed to include their care plans and other records. This home is one of three owned by the registered provider and all are in close proximity. A total of eight hours were spent in the three homes and included the case tracking of three service users including a review of their records, discussions with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection? What they could do better:
The recruitment of staff was very detailed and records demonstrated a robust system, however one newly appointed member of staff commenced work in the home prior to the receipt of a satisfactory Criminal Bureau records (CRB) check, until all necessary checks are in place staff should not have access to service users as this could put them at risk. DS0000012680.V280680.R01.S.doc Version 5.1 Page 6 The risk assessments completed need further attention to ensure that all areas of identified need are fully assessed. The daily records in the home are not fully documenting any incidents that occur and there is a lack of evidence of actions taken or reference to other documentation, e.g. incident reports that are completed. 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. DS0000012680.V280680.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000012680.V280680.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed on this inspection. DS0000012680.V280680.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 6, 7 and 9 The lack of detailed incident reports, risk assessments and records maintained in the service user files puts the service users at risk of not having their needs fully met. EVIDENCE: Care plans are written to a high standard with clear guidelines for staff to ensure a consistent approach with the service users. There is a useful yearly overview completed to demonstrate progress made and update records as to current level of needs and the use of short term care plans ensures the service user knows where they are aiming and it is evident through discussions with service users and the records that they are involved in developing goals. Discussions with the service users showed evidence of them being able to make decisions about their day-to-day lives and the level of support required is individually discussed and agreed. DS0000012680.V280680.R01.S.doc Version 5.1 Page 10 Risk assessments are completed for identified need and the philosophy of the home is clearly to manage risk without restricting the service users own choice. There was however one service user identified who spoke about a service user from another of the Agape Homes who had taken money from her, it was evident that the home had begun to investigate this further as the incident was reported to have taken place at day care, however the service users notes did not evidence this incident and there were no risk assessments in place to support the risk identified. Another service user spoke about a number of issues they were unhappy with and whilst it is evident that the full multi disciplinary team is involved in planning the care, the records in the home do not fully document all the issues and the number of incidents that are occurring. On the day of the inspection it was reported that this service user had been upset and angry and making accusations and complaints to the staff, the daily records contained no reference to this. This service user also has a history of making accusations and although there is an on call system for support, the staff work predominately alone and there is little protection for staff or the service user against allegations. DS0000012680.V280680.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 15 and 16 Service users are supported to develop and maintain relationships and their rights recognised in daily life. EVIDENCE: The service users spoke about their families and friends and how they are supported to maintain contact both within and outside the home. It was evident through discussion with the staff team in the home that relationships are supported and they encourage the service users to develop these with the necessary guidance and advice from relevant professionals to assist with informed choices. One service user spoke about a relationship they were in, it was evident through discussion that they were offering support and guidance to ensure the service users were being given the necessary advice the home was trying to support the relationship without imposing restrictions whilst trying to ensure all parties were being protected. DS0000012680.V280680.R01.S.doc Version 5.1 Page 12 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 the following standard(s): EVIDENCE: These standards were not assessed at this inspection. DS0000012680.V280680.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 23 The homes policies, procedures and practices protect service users. EVIDENCE: The home has clear policies in relation to abuse awareness and staff were able to discuss how they would deal with any concern raised. There is a key worker system in place to ensure the service users have 1-1 time and are encouraged to discuss any concerns about their care in the home. The concerns raised by service users during the inspection were discussed and the registered provider agreed to further investigate and make the appropriate referrals if required. DS0000012680.V280680.R01.S.doc Version 5.1 Page 14 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 the following standard(s): EVIDENCE: These standards were not assessed at this inspection. DS0000012680.V280680.R01.S.doc Version 5.1 Page 15 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 36 The commencement of new staff prior to receipt of all necessary checks could put service users at risk. EVIDENCE: The staff files showed evidence of a detailed recruitment procedure including the uptake of references, health declarations and Criminal records Bureau (CRB) checks. One newly appointed member of staff had all the necessary documentation, however it was evident they had commenced work in the home prior to a satisfactory CRB being received. A formal supervision process has been implemented and the staff spoken to confirmed they received regular supervision. DS0000012680.V280680.R01.S.doc Version 5.1 Page 16 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home is well run with procedures in place to ensure the safe management of the health and safety of the service users. EVIDENCE: The registered providers of the three Agape homes have worked in this field for many years and they demonstrate a good level of understanding of the needs of the service users, both are working towards the registered managers and National Vocational Qualification (NVQ) level 4 qualification. The quality assurance system includes questionnaires to the service users along with regular house and staff meetings to assess if the service is meeting the needs of the service users. The risk assessments for the use of hot water have been completed for all service users. The registered provider completes a monthly audit of the home and fully assesses the home including the environment for any safety issues. There were no health and safety issues identified at the time of this inspection. DS0000012680.V280680.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 3 X X 3 X DS0000012680.V280680.R01.S.doc Version 5.1 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 YA9 YA9 YA34 Good Practice Recommendations Risk assessments should be developed for all areas of identified need as discussed on inspection re service users identified. The daily records in the home should include reference to incidents with reference to any further documentation completed. The commencement of new staff should be in line with CRB requirements. DS0000012680.V280680.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Northamptonshire Area Office 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
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