Inspection on 21/09/07 for Agatha House

This inspection was carried out on 21st September 2007.

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 found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Agatha House 02/07/08

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Agatha House Harold Court Knightswood Close Edgware Middlesex HA8 8FR Lead Inspector Robert Bond Key Unannounced Inspection 21st September 2007 10:00 Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 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 Agatha House DS0000068781.V351143.R01.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 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. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Agatha House Address Harold Court Knightswood Close Edgware Middlesex HA8 8FR 020 8958 2187 TBA 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) London Borough of Barnet David Oginni Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection No previous inspection Brief Description of the Service: Agatha House is a purpose-built care home for six adults with mild to moderate learning disabilities. One of the residents is over retirement age. The home is operated by the London Borough of Barnet, and is part of the re-provision arrangements following the closure of the Oaktrees care home. All the residents and most of the staff transferred from Oaktrees. The new home is all on the ground floor, but with tenants of the Council’s learning disability outreach service above. The building is light, airy and spacious and is designed for use by residents with physical disabilities. It is wheel-chair accessible throughout including the garden. The bedrooms are large and have en-suite facilities. The premises are in a cul-de-sac that is part of a housing estate in Edgware. Local shops, facilities and transport links are nearby. The charges for a place at the care home have not been made available to the CSCI. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector obtained from the Registered Manager in advance of the inspection a completed Annual Quality Assurance Assessment (AQAA) and also obtained the CSCI Registration Report for the home. As the home was first registered in January 2007, this inspection was the first CSCI inspection of a new service and therefore so far as possible the home’s performance in reaching the anticipated outcomes for all 43 National Minimum Standards (NMS) was assessed. The NMS used were those published in the Department of Health’s booklet National Minimum Standards and Care Home Regulations for Care Homes for Younger Adults. The unannounced inspection took place on 21st September 2007 and lasted 5 hours. Unfortunately the Registered Manager was on leave that day and the Deputy Manager was on sick leave. The Inspector was therefore ably assisted by the Senior Support Worker (SSW). During the inspection, the Inspector interviewed the SSW, talked to other staff members, met residents, toured the premises and examined a range of records. The care file of one resident chosen at random was examined in detail (case-tracked). The Inspector subsequently had email contact with the Registered Manager. The home is currently fully occupied by residents, and the staff team is almost complete. The ethnicity of the residents is described as follows by the Registered Manager: 5 residents are ‘white British’, 1 resident is ‘Iraqi Jew’. Equality and diversity issues have been satisfactorily addressed by the care home. The Inspector found that one of the outcomes of standards was exceeded, 29 outcomes were fully met, and 13 outcomes were only partially met. This led to the Inspector making 17 requirements and 1 recommendation. This is a comparatively high number of requirements that partly results from the home being inspected for the first time. It is likely that the number of requirements will fall subsequently. What the service does well: The premises have been attractively designed and built so that they are level, on the ground floor, spacious and airy. There is a large car park at the front, and an attractive level garden at the rear. The whole premises are suitable for wheel-chair users. The bedrooms are large, single and all have en-suite facilities. The home is well furnished and equipped. Parts of the home are fitted with ceiling mounted hoists for the benefit of residents with a physical disability. The home displays its CSCI registration certificate. The Statement of Purpose and Service Users’ Guide are in place. Standard Resident Contracts are used. Residents are well consulted concerning the operation of some aspects of the home, and play a good part in helping the home operate. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 6 Personal risk management plans are in place that identify for staff how personal care should be provided. ‘Service user skills development’ forms identify goals for residents and also identify the staff support necessary to assist residents achieve those goals. Confidentiality is maintained. Use is made of a local day centre. All staff members have been trained in the Council’s policy and procedure for the protection of vulnerable adults (safeguarding adults). All permanent staff members have obtained or are studying for NVQ awards in care. Staff have been recruited in ways that support and protect residents. The managers of the home are well qualified. The home has a quality monitoring system in place and operates following a good range of policies and procedures. What has improved since the last inspection? What they could do better: The home must not provide accommodation to any resident unless they have obtained a copy of the care management assessment for that person so as to be able to fully meet their assessed needs. The assessment has to be kept for subsequent inspection. The Service User Plan has to be prepared in consultation with the resident so that aims and goals reflect the resident’s wishes. Evidence of this consultation will be available if the resident signs and dates the plan. Evidence is required that the Service User Plan has been reviewed at least six monthly so that current needs and goals are identified. Review notes must show who was present. The Service User Plan has to be in a format that the resident can understand. Residents must be consulted about their interests and ways must be found to increase the extent of activities available. A nutritionist must be used to assist in a review of the food and drink consumed by residents so that their dietary needs are being fully met. The weight of all residents must be monitored and recorded on a regular basis as part of a health action plan for the benefit of residents. All administration or non-administration of medication must be accurately recorded and systems must be in place to spot errors quickly in order to offer sufficient protection to residents. Additional staff training in medication administration is required. When a complaint has been made, it must be fully investigated, and the record show what action and outcome is achieved in order to improve the life of residents. The premises could be made more homely for residents by the addition of floor coverings, cushions and table clothes. The windows must be fitted with proper opening restrictors in order to protect residents to a greater extent. Further professional advice must be obtained concerning signage for emergency exits and suitable locking/opening arrangements for emergency exits in this type of care home in order to protect residents from the effects of fire. En-suite bathrooms must contain a cabinet or a similar item of furniture that is suitable for the storage of personal toiletries in order to offer more privacy and dignity for residents. A review must be undertaken of staffing Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 7 levels and staff rotas to ensure that all residents’ needs are being met. All staff employed at the care home must receive supervision at the required frequency as a means to enhancing the quality of care for residents. Regulation 26 visits must be undertaken at least monthly and a report submitted to the CSCI, as a means of assuring quality control for the benefit of residents. The contents of first aid boxes must be audited regularly and the boxes refilled so that the required items are present when required. To aid this process, the box must contain a list of the items to be placed within it. 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. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 8 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 Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use this service experience adequate outcomes in this area This judgement has been made using available evidence including a visit to this service. Prospective residents have sufficient information to help them make an informed choice about where to live, and prospective residents did visit the home in advance of moving in, but the home did not produce the evidence that all prospective residents’ individual aspirations and needs had been fully assessed in advance. Residents know that the home they have chosen will meet their needs and aspirations in a satisfactory manner and each resident has a standard service contract. EVIDENCE: The Registered Manager was on leave on the day of the inspection and the Senior Support Worker (SSW) on duty was unable to locate for the Inspector a copy of the home’s Statement of Purpose and Service Users’ Guide. However both these documents would have been seen by the CSCI inspector who recommended that the home be registered. Therefore it is assumed that the documents meet the required standards. The existing residents all transferred together from their former care home. The Inspector selected one resident at random and asked to see his/her care file. The file contained a document entitled ‘My moving on plan’ which demonstrated that careful thought, consideration, and consultation with the resident had taken place when the closure of Oaktrees was being planned. The Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 10 SSW said that assessments of each resident of Oaktrees had been undertaken by a social worker from London Borough of Barnet, and that senior support workers from that home had also been involved. No copy of that assessment however could be located at Agatha House. NMS 2.2 requires the care home to have at least a summary of any care management assessment undertaken. The SSW confirmed to the Inspector that all six residents had been correctly placed. The Inspector spoke to every resident and all confirmed that they were happy at the home. The Inspector noted that one resident is over retirement age but he was assured that this was not a problem for her or the other residents. Physical disability needs were seen by the Inspector to be being met. Cultural and religious needs had been assessed. The SSW explained that prospective residents of Agatha House could see the new home being built from their old home at Oaktrees and they were able to choose bedroom colours and curtains. There was a one week period for prospective residents to view the new home prior to moving in. The Inspector noted the existence of a ‘standard service contract’ for each resident. The example case-tracked had been signed by the resident, the key worker and the home manager. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Due to a lack of residents’ signatures, and service user plans not being in userfriendly formats, it does not appear that all residents do know that their assessed and changing needs and personal goals are reflected in their individual Plan. Residents do make decisions about their lives with assistance as needed, but further evidence is necessary. Residents are well consulted concerning the operation of some aspects of the home, and play a good part in helping the home operate. Residents are sufficiently supported to take risks as part of an independent lifestyle and may know that information about them is handled appropriately and maintained confidentially. EVIDENCE: The Inspector searched the care file of the resident he was case-tracking and located a ‘comprehensive care plan’. Without a comprehensive assessment document being available it is not possible to say that the care plan was based on the assessment, as is required. The care plan was not dated nor signed by anyone but part the way through the plan made reference to the resident having moved into Agatha House. The care plan was in a format that Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 12 encouraged a person centred approach, but it had not been completed in this way. In other words the form required completion in the first person, but it had been completed in the third person. The care plan was not in a format that residents of the home would readily appreciate such as having key phrases in large print and the use of pictures or photographs. The file contained two sets of review notes dated February 2006 (held at Oaktrees) and July 2007 (held at Agatha House). Thus there appeared to be a 17 month gap between reviews, not the maximum six month gap required by NMS 6.10. Neither set of review notes indicated who had been present at the review meeting or who had written the notes. The SSW said normally review meetings were attended by the manager or deputy manager of the home, a representative of the day centre, the key worker and the resident. The duty social worker and relatives of the resident were also invited. The review notes were of a high standard in terms of content and presentation and the care plan had been updated following the last review. The SSW reported that in addition to residents attending reviews, their opinions are sought and included in care planning documents, but as indicated above the evidence is lacking. However the Inspector did see minutes of weekly Residents Meetings where consultation took place. The SSW added that residents are supported to manage their own finances where possible, and that surveys are undertaken. One resident told the Inspector she had a key to her bedroom. Another resident said she had chosen to stop attending the day centre. The Resident Meeting minutes confirmed that residents help choose the food menu. The SSW reported that residents assist with shopping, cleaning, dishwasher and bringing their dirty clothes to the laundry. The latter was observed by the Inspector. One resident told the Inspector she enjoys helping with the shopping. The Inspector noted on the file case-tracked that a ‘personal risk management plan’ dated 23/06/07 was present and that this document had been signed by the manager, keyworker and the resident. This document provided staff members with the detail of actions necessary (amongst other things) to promote independence. A separate document entitled ‘service user skills development’ identified goals for residents and also identified the staff support necessary to assist residents achieve those goals. This is a good concept. Three residents have their own bank accounts. Several have keys to their own bedrooms, one resident is enabled to enter and exit the care home alone by being given the entry code. One resident has the use of an adapted vehicle for staff to drive him around in. The Inspector read the home’s confidentiality policy, and observed that care files were kept in a locked office. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 13 Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have some opportunities for personal development, and are able to engage in appropriate activities in the home, and in the local community, family contact is encouraged, but full use is not made of the local day centre. Residents’ rights and responsibilities are sufficiently recognised, but residents may not have a sufficient and healthy diet. EVIDENCE: The SSW reported that one resident is supported to attend the church of her choice. Another resident was noted to be non-practicing Jewish. None of the residents are engaged in work or volunteering outside of their home, none attend college, but five out of the six residents attend a nearby day centre. One resident has chosen to no longer attend the day centre, saying that she has now retired. The Inspector noted a daily activity programme for one resident. Whilst at the day centre, there is the opportunity to undertake educational activities. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 15 The SSW reported that shopping, the cinema, going to the pub and restaurant or hairdresser were all popular activities. She was however concerned that staff levels were lower at Agatha House than at Oaktrees and hence fewer activities were possible. On the day of the inspection 5 residents were in the home, not at a day centre, and no particular activities were noted to be going on. The level of activities provided and undertaken in the home or in the community does need to be reviewed. The SSW added that the home was very well established in the locality but that no-one from the community (such as organised schoolchildren or church group) ever visited the home. Relatives are invited to attend reviews and special events such as summer bar-b-que and Christmas party. There was said to be insufficient interest in a relatives meeting. Two residents go to stay with relatives occasionally. Visitors are said to be welcome at any time. Residents were seen to help with the home’s routine chores, and good staff resident interaction was observed by the Inspector. Staff knock on bedroom doors before entering. Residents help choose the food menu as evidenced by the minutes of the Residents’ Meeting. The Inspector observed residents eating their lunch. This was only a snack lunch, the most substantial meal being egg on toast. Not all residents were eating. The SSW said that residents are supported to make their own breakfasts and lunches of their own choosing. The main meal is dinner at 6pm which is a two course meal prepared by staff. Residents can choose to have a drink in the evening but no supper is served. Residents with continence issues are not given a drink in the evening said the SSW. The food and drink situation must be reviewed with the help of a nutritionist in order to ensure that all residents are receiving a nutritious and sufficient diet, with sufficient fluids. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, and 21. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive good personal care mostly in the way they prefer and require, but not always the same gender personal care that they prefer. Physical health needs are not being fully met as residents’ weights are not being recorded sufficiently frequently. The home’s records for the administration of medication are not sufficiently accurate to adequately protect residents. Efforts have been made to ensure that the ageing, illness and death of residents are handled with respect and as the individual would wish. EVIDENCE: The care file case-tracked contained a ‘personal risk management plan’ that provided staff with detailed actions necessary in order to met the personal care needs of that particular resident. Each resident has a designated key worker. Efforts have been made (although not always successfully) to provide same gender personal care. Specialist equipment has been installed in the home such as a ceiling mounted hoist to enable the care needs of the resident who has a physical disability to be safely met. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 17 The care plans do not contain a ‘health action plan’ but they do show a record of health treatment actions and dates. Two separate GP practices are used. The SSW reported that both undertake annual reviews of medication. The CTPLD monitor epilepsy in one resident, and other health issues in another resident. Community opticians and dentists are used. The home keeps a record of residents’ weights on a monthly basis but gaps were noted in the record examined. The Inspector examined the home’s medication storage arrangements, which were satisfactory, and the home’s records of medication administration, which were not. Within the limited record examined, three days for six residents, there were two gaps where no initial or letter appeared, and an instance of using a code letter that was not in the approved list. The returned medication book was seen to be satisfactory. No residents self-medicate. Boots the Chemist provide the MDS system and undertake their own annual inspections and staff training. The care plan examined by the Inspector did not contain a section covering the topics of ageing and death. However a letter on the file did show that 5 years ago efforts had been made to determine a relative’s wishes in this respect, without apparent success. The SSW reported that the Registered Manager had been involved in preparing wills for each resident. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents may feel that their complaints are listened to, but not that they are acted upon. Residents however are sufficiently protected from abuse, neglect and self-harm. EVIDENCE: The Inspector examined the home’s complaints leaflet, which included pictures, and the London Borough of Barnet’s complaints procedure. Both were suitable. No complaints had been logged in the home’s complaints book, however variations of the same complaint appeared in the previous four sets of minutes of the Residents’ Meeting. The complaint was from one resident that he/she was disturbed at night by noise coming from the outreach accommodation on the floor above. Where a complaint is made and recorded, NMS 22.7 requires that the record also shows details of the investigation undertaken, the action taken, and the resulting outcome. Therefore the complaints recording system at Agatha House will have to be revised as only the complaint itself is being recorded. The Inspector noted a training record that demonstrated that all the home’s staff had received training in the protection of vulnerable adults. The home was seen to have the London Borough of Barnet’s POVA procedure in the office. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that is comfortable but not very homely and not sufficiently safe due to the lack of adequate window opening restrictors, and fire escape signs. Residents’ bedrooms suit their needs and lifestyles and help to promote independence sufficiently, their en-suite bathrooms do not provide sufficient privacy and meet individual needs due to the absence of cabinets. Residents’ communal space is substantial and appropriate, residents are provided with or assisted to obtain specialist equipment, and the residents’ home is very clean and hygienic. EVIDENCE: The Inspector toured the premises inside and out and found them to be suitable for their stated purpose, accessible, and well maintained. Communal areas are well decorated, furnished and equipped. A recommendation is made however concerning how to make the premises appear more domestic or homely. The premises are not however sufficiently safe as the window restrictors do not prevent a resident from opening a downstairs window fully to climb out, or if the window is left ajar, do not prevent an intruder from opening Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 20 the window fully to climb in. In addition, potential fire exits are not marked as such, and the keys to fire exit doors are kept out of sight. As a result residents could not escape a fire unless assisted by staff members to do so. Further advice from an expert on fire evacuation is indicated. The Inspector was invited by a resident to see her bedroom. It was attractively personalised. All the bedrooms are single, of a good size and have en-suite facilities. The bedrooms are appropriately furnished and equipped, although all have wooden floors with no carpeting or mats regardless of the individual needs or abilities of the residents using the rooms. The bedrooms are lockable but have a monitoring system that alerts staff if a door is opened at night. The home has sufficient communal bathrooms and toilets that are equipped to a good standard but the en-suite bathrooms do not contain a cabinet for personal toiletries. The home has sufficient communal areas that are well furnished and decorated but there are no floor coverings over the wooden floors, few cushions and no table clothes, all of which makes the ambience slightly institutional. The home has suitable adaptations and equipment for residents with a physical disability, for example ceiling mounted hoists. The Inspector found the home to be very clean. No smells or other hygiene issues were noted. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by a sufficiently well qualified staff team, who have job descriptions, but the staff team as currently deployed may not as effective as possible due to a lack of activities and outings for residents at weekends. Residents are well supported and protected by the home’s recruitment policy and practices, staff members are receiving training that is sufficient to meet residents’ needs but they do not receive sufficient formal supervision, which may have a detrimental effect on residents. EVIDENCE: The SSW reported that the home was fully staffed with the exception of one day and one night worker but there were no plans for recruitment. The rotas enable the home to have 2 staff on duty each shift, sometimes 3. No agency staff members are used as the home can use relief staff employed by the London Borough of Barnet. At night one staff member sleeps in the premises whilst another remains awake. A domestic assistant is employed on weekdays only. A part-time administrative assistant is employed via the Council’s relief bank. The Inspector examined a sample staff rota. The Inspector examined sample job descriptions. The home has a manager, deputy manager, senior support worker, and support worker grades. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 22 The Registered Manager reports in the AQAA that 4 out of 7 support staff have obtained at least NVQ level 2 in care, and the remaining staff are committed to obtaining the award. Concerning whether or not the home has an effective staff team in place at all times, the Registered Manager identifies in the AQAA the need to achieve more flexibility in the staff rotas to enable more weekend activities and outings for residents to be offered. As a lack of activities is an aspect the Inspector has already commented upon, a requirement is made concerning staffing levels. The Inspector examined notes of staff meetings. The SSW said the home has a good staff team with the correct mix of skills. The Inspector asked the SSW which members of staff had been recruited since the home opened and existing staff had been transferred from Oaktrees. The Inspector was furnished with one name and asked to see evidence that appropriate references and a CRB had been obtained. These were not available in the care home as the employee was employed centrally by London Borough of Barnet. The required evidence was subsequently emailed to the Inspector. The Inspector examined the ‘staff training profile’ maintained within the care home, and noted the records of training undertaken by each member of staff. A training plan for the year ahead was requested by the Inspector but could not be located by the SSW. The Registered Manager subsequently explained that the home supplies London Borough of Barnet with a list of training needs, and they develop a training plan for the whole of ‘Adult Social Care’. Individual training needs are discussed in one to one staff supervision sessions. The Inspector examined the supervision record for one member of staff chosen at random. He had received only two supervision sessions during the previous 12 months, whereas the NMS require all staff to have at least 6 supervision sessions per year. However the Registered Manager subsequently advised the Inspector that the member of staff in question had been on unpaid leave for 3 months of that time. Nevertheless, there does appear to be a failure to provide all staff with sufficient formal professional supervision sessions, which the SSW reported should occur 6 weekly in terms of the home’s own supervision policy. The evidence is the Regulation 26 reports submitted to the CSCI by the Service Manager- In-House Services, London Borough of Barnet. There are 5 reports available since the home opened 9 months ago. Those dated 29/05/07, 24/07/07 and 08/08/07 all say in the action required section, “Ensure staff supervisions are happening regularly”, which suggests some staff members were not receiving regular supervision as recently as last month. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 23 Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home where the managers are competent, well qualified, approachable and open to other people’s ideas. Residents’ views are taken into account, but the quality monitoring system does not meet the Regulations in terms of Regulation 26 report frequency. Residents’ rights and best interests are sufficiently safeguarded by the home’s policies and procedures, including those for record keeping. However the health, safety and welfare of residents are not sufficiently promoted and protected. EVIDENCE: The SSW reported to the Inspector that both the Registered Manager and the Deputy Manager have obtained the Registered Manager Award. The SSW added that the managers responsible for the home are all approachable and open to other people’s ideas. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 25 The SSW advised that a quality assurance survey has been undertaken. The Registered Manager writes in the AQAA about a quality monitoring systems. Since the home has been open (nine months), five Regulation 26 reports have been completed by the Service Manager- In House Services, London Borough of Barnet. Copies of these reports do not seem to have been sent as required to the CSCI, but they were emailed subsequently to the Inspector. The Regulations say that monthly reports are required as part of the quality monitoring system. The home was seen by the Inspector to have a full set of policies and procedures in place. The Inspector was told by the SSW that residents have personal accounts held with the London Borough of Barnet. The Inspector was not able to check the financial records but expects that they are audited internally by a Council employee. The Inspector checked various health and safety aspects in the home such as hot water supply and temperature recording, and the operation of the call bell system. The Inspector noted a fire safety report, a gas safety report, health and safety officer report, and an environmental officer report. All were satisfactory. The Inspector asked to see a service contract for the ceiling mounted hoists. One was not available but the Registered Manager subsequently reported that the hoists were still covered by their guarantee and a service contract would be entered into when the guarantee period expired. The Inspector examined a first aid kit within the home and found the box did not contain a list of contents to aid in its regular auditing. A requirement is made. Requirements have also been made in the environment section concerning window restrictors and fire exits, both of which also have serious health and safety implications for residents and staff. The Inspector did not consider the insurance and budget aspects of the home as the SSW did not have access to the home’s accounts. However as the home is operated by the London Borough of Barnet, the Inspector considers it to be very likely that all proper financial procedures are in place. Agatha House DS0000068781.V351143.R01.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 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 3 2 2 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 4 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 3 2 3 3 2 3 Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No previous 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 YA2 Regulation 14(1)(b) Requirement Timescale for action 01/12/07 2 YA2 3 YA6 4 YA6 5 6 YA6 YA14 7 YA17 The home must not provide accommodation to any resident unless they have obtained a copy of the care management assessment for that person. 17(1a)Sch3(1a) Each resident’s preadmission assessment has to be kept for inspection at the care home. 15(2)© The Service User Plan has to be prepared in consultation with the resident. Evidence of this consultation will be available if the resident signs and dates the plan. 15(2)(b) Evidence is required that the Service User Plan has been reviewed at least six monthly. 15(1) The Service User Plan has to be in a format that the resident can understand. 16(2)(n) Residents must be consulted about their interests and ways must be found to increase the extent of activities available. 16(2)(i) A nutritionist must be used to assist in a review of the DS0000068781.V351143.R01.S.doc 01/12/07 01/12/07 01/12/07 01/02/08 01/01/08 01/12/07 Agatha House Version 5.2 Page 28 8 9 YA19 YA20 12(1)(a) 13(2) 10 YA22 22 11 12 YA24 YA24 13(4)© 23(4)(b) 13 YA27 23(2)(m) 14 YA33 18(1)(a) 15 YA36 18(2) 16 YA39 26 17 YA42 13(4) food and drink consumed by residents. The weight of all residents must be monitored and recorded on a regular basis. All administration or nonadministration of medication must be accurately recorded and systems must be in place to spot errors quickly. Additional training is required. When a complaint has been made, it must be fully investigated, and the record show what action and outcome is achieved. The windows must be fitted with proper opening restrictors. Further professional advice must be obtained concerning signage for emergency exits and suitable locking/opening arrangements for emergency exits in this type of care home. En-suite bathrooms must contain a cabinet or similar furniture that is suitable for the storage of personal toiletries. A review must be undertaken of staffing levels and staff rotas to ensure that all residents’ needs are being met. All staff employed at the care home must receive supervision at the required frequency. Regulation 26 visits must be undertaken at least monthly and a report submitted to the CSCI. The contents of first aid boxes must be audited regularly and the boxes DS0000068781.V351143.R01.S.doc 01/11/07 01/11/07 01/11/07 01/01/08 01/01/08 01/01/08 01/02/08 01/12/07 01/11/07 01/12/07 Agatha House Version 5.2 Page 29 refilled. To aid this process, the box must contain a list of the items to be placed within it. 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 YA24 Good Practice Recommendations The premises could be made more homely by the addition of floor coverings, cushions and table clothes. Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Agatha House DS0000068781.V351143.R01.S.doc Version 5.2 Page 31 - 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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