Inspection on 15/08/07 for Agnes House

This inspection was carried out on 15th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Agnes House 02/05/06

Agnes House 13/09/05

Agnes House 04/04/05

Agnes House 10/11/04

Agnes House 07/06/04

Agnes House 05/02/04

Similar services:

Applegarth

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Agnes House Wyggeston`s Hospital Hinckley Road Leicester LE3 0UX Lead Inspector Kim Cowley Unannounced Inspection 15th August 2007 11:30 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 Agnes House DS0000036495.V341642.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 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. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Agnes House Address Wyggeston`s Hospital Hinckley Road Leicester LE3 0UX 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) 0116 2559173 0116 2543008 clerk.wyggeston@zen.co.uk Wyggeston’s Hospital Mrs Ellen Marcia Tebbutt Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability over 65 years of age of places (20), Sensory Impairment over 65 years of age (5) Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers SI(E) No person falling within category SI(E) may be admitted into the home when 5 persons who fall within category SI(E) are already accommodated within the home Service User Numbers PD(E) No person falling within category PD(E) may be admitted into the home when 20 persons who fall within category PD(E) are already accommodated within in the home 2nd May 2006 2. Date of last inspection Brief Description of the Service: Agnes House is a purpose built home set in five acres of landscaped gardens. It is situated close to Leicester city centre. It is registered for 26 older people, some of whom have physical disabilities including sensory impairment. Accommodation is on two floors accessed by a passenger lift. There is a large lounge and dining area on the ground floor, which leads to a conservatory overlooking a sensory garden. A further lounge is situated on the first floor. All the bedrooms all en-suite. Agnes House shares some facilities with the adjacent William House, a sheltered housing scheme. These include a chapel, library and meeting room. Current fee levels at the home range from £319 to £475 per week depending on care needs. Inspection reports are available at the home, or can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the Registered Manager. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included a visit to the home and inspection planning. Prior to the visit, the inspector spent half a day reviewing information relating to the home. During the course of the inspection, which lasted four hours, the inspector checked the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means the inspector looked at the care provided to three residents living at the home by meeting them; talking with the staff who support their care; checking records relating to their health and welfare; and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home, including health and safety and management issues, were examined. The inspector also met four other residents, the Manager, Deputy, Responsible Individual/Administrative Manager, and two members of the care staff team. What the service does well: Agnes House provides spacious and comfortable accommodations for residents. It is decorated and maintained to a high standard. All areas inspected were exceptionally clean and fresh. The home has extensive gardens with many features including a koi carp pond and waterfall, lawns, and woodland walkways. One resident commented, ‘I love the gardens here. They are out of this world.’ Regular activities are provided in the home including music and movement, bingo, trips out, and coffee mornings. Residents are encouraged to determine their own lifestyles, and care plans showed them being given choice about all aspects of their lives. One resident told the inspector, ‘I can do what I like here. I have my own routine and it’s different to everybody else’s but the staff don’t mind at all.’ Staff are well qualified and experienced. During the inspection they were observed as being professional and caring in their approach to residents, and to communicate well with them. All residents interviewed praised the staff team. Comments included, ‘What I like about the staff is that they speak so nicely to us’, ‘The staff always come and say: “Is there anything you need?”’, and ‘We are very well cared for here.’ Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 7 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 Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 8 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): Quality in this outcome area is good. Residents’ needs are assessed prior to admission to ensure the home is suitable for them. This judgement has been made using available evidence including a visit to this service. (Standard 3 was inspected.) EVIDENCE: The Manager or the Deputy assesses all residents who are interested in coming to the home. Assessments usually take place in their own homes or in hospital. Relatives and health professionals are consulted to get their views on the resident’s needs. These steps help to ensure the home is suitable for the resident in question and that staff can care for them properly. Prospective residents are invited to visit the home for lunch or for the day. They also have the option of having a respite stay to get a feel of the home. Once admitted, each resident has a trial period of at least four weeks. One resident commented, ‘My relatives found this home for me. Then I came for the day and it attracted me very much.’ Another said, ‘I heard about this home by word of mouth. I visited and I like it immediately.’ Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 9 Standard 6 was not inspected, as this service does not provide intermediate care. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is excellent. Staff in the home, and in the wider community, meet residents’ health and personal care needs. Medication is safely managed and administered. Residents are treated with respect. This judgement has been made using available evidence including a visit to this service. (Standards 7, 8, 9, and 10 were inspected.) EVIDENCE: Care plans are in place to ensure that residents’ health, personal and social needs are met. All residents case tracked had the necessary risk assessments in place. Records showed some residents improving and becoming more independent since they had been in the home. All residents interviewed said they were pleased with the care at the home. One said, ‘I had many falls at home but since I’ve been here I’ve had no falls.’ Records showed that care plans are reviewed at least once a month. The care plans inspected were holistic, covering a broad spectrum of needs, likes and dislikes. As well as basic care like bathing and toileting, other aspects of how a resident likes to be cared for were addressed. For example, a record is made of how many pillows a resident likes, preferred bed time, and whether Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 11 they want their ensuite door open or shut. And a section of the care plan called ‘Social Needs and Relationships’ addresses residents’ views on talking about relatives/friends, mixing with other residents, and keeping in contact with friends. This attention to detail helps staff to provide individual and sensitive care to residents at the home. Residents are registered with GPs at local surgeries. District Nurses visit the home when necessary to provide treatment. Records showed that residents have access to a full range of health care treatment including input from chiropodists, dieticians, dentists, and opticians. Medication is administered by senior staff who have been trained in house and by the home’s contract pharmacist. The Manager and Deputy have recently had refresher training to ensure their skills in this area are up to date. The Manager said that although carers do not administer medication, they attend training events to learn about the side effects of medication. All residents interviewed said staff carried out personal care in a way that preserved their privacy and dignity. Staff were seen to be polite and respectful when caring for residents. Instructions to staff recorded in care plans showed that each resident’s privacy and dignity is a priority in the home. One resident commented, ‘What I like about the staff is that they speak so nicely to us.’ Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. Daily life and social activities enable residents to lead purposeful lives. Good nutrition is a priority in the home. This judgement has been made using available evidence including a visit to this service. (Standards 12, 13, 14, and 15 were inspected.) EVIDENCE: Regular activities are provided in the home including: • • • • • • • • music and movement bingo trips out coffee mornings scrabble afternoon cream teas arts and crafts ‘takeaway’ evenings (for example fish and chips or curry) Residents told the inspector they were pleased with the activities on offer and made some suggestions for some additional activities they would like. These included a ‘trolley shop’, which could be brought round the home, sing-a-longs with piano or accordion accompaniment, and music from the shows. These Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 13 suggestions were reported to the Manager who said she would give them full consideration in consultation with residents. If they wish, residents can make use of the facilities in the adjacent sheltered housing complex. These include a hairdressing room, activities room, library and chapel. A Church of England minister is based on site and provides weekly services for residents. A Catholic priest also visits. Residents are encouraged to determine their own lifestyles, and care plans showed them being given choice about all aspects of their lives. One resident told the inspector, ‘I can do what I like here. I have my own routine and it’s different to everybody else’s but the staff don’t mind at all.’ Relatives/friends are welcome at the home at any time and invited to share meals with residents and feel part of the home. A qualified cook and four catering assistants are employed in the home. Residents have the opportunity to make menu suggestions and records showed varied and nutritious meals being offered. All residents interviewed praised the food and the following comments were made: ‘The food is very nice and very well cooked.’ ‘I like the salads we have best – they do a great salad.’ ‘The staff come and ask us what we want for dinner and we pick what we like.’ ‘I definitely like the food here.’ ‘We are given plenty of food.’ ‘We have a menu and we choose what we want.’ ‘I’m not keen on rice pudding so if they have that I have something else instead.’ ‘I don’t like tomatoes so they never give them to me.’ Residents are encouraged to drink fluids. There is a water dispenser in the dining room for both residents and staff to use, and soft drinks (kept on a trolley in the main lounge) are made available to residents at all times. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 14 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 good. Residents feel able to talk to staff about any concerns they might have and staff are trained in safeguarding adults. This judgement has been made using available evidence including a visit to this service. (Standards 16 and 18 were inspected.) EVIDENCE: The home’s complaints procedure is displayed on a notice board and residents are given a copy when they move in. They are also reminded of it at residents’ meetings. There have been no complaints received since the last inspection. All residents interviewed said they would tell a member of staff if the had a complaint. One resident commented, ‘If I wasn’t happy about anything I’d tell the Manager or the Deputy – they are the people in charge. I’d arrange a meeting with them.’ Staff are trained in safeguarding vulnerable adults during their induction, and the majority have had further training in this area. The home has a whistle blowing procedure in place, and a procedure for reporting suspected abuse. In discussions all staff were clear about what they would do if they had concerns about a resident’s well being. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is excellent. Residents live in an environment that is comfortable, well decorated and maintained to a high standard. This judgement has been made using available evidence including a visit to this service. (Standards 24 and 30.) EVIDENCE: The home, which was purpose built, provides spacious and comfortable accommodations for residents. It is decorated and maintained to a high standard. There are nine bedrooms downstairs, and 17 bedrooms upstairs with a lift for access. All bedrooms are ensuite. There are ample communal areas including two lounges, a dining room, and a conservatory. They are laid out so residents sit in small groups. The home has extensive gardens with many features including a koi carp pond and waterfall, lawns, and woodland walkways. One resident commented, ‘I love the gardens here. They are out of this world.’ Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 16 Since the last inspection the following improvements have been made to the home: • • • • • four bedrooms have been refurbished standard lamps for reading have been purchased for the conservatory. there are new coffee tables in the main lounge. a craft storage are has been created in the conservatory. there is a new flat screen TV/video/DVD in the main lounge. . Three permanent cleaners are employed and all areas inspected were exceptionally clean and fresh. Residents’ clothes are washed and ironed in the main laundry in the sheltered housing complex, although the home has its own washing machine. This is used for small items and residents who need special washing powders due to allergies. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 17 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 good. Well-trained, friendly and professional staff meet residents’ needs. This judgement has been made using available evidence including a visit to this service. (Standards 27, 28, 29, and 30 were inspected.) EVIDENCE: During the inspection staff were observed as being professional and caring in their approach to residents, and to communicate well with them. The home is well staffed and has dedicated catering/cleaning staff which means the care staff can focus on the residents. Since the last inspection extra staff have been put on duty between 9am and 1pm to cover the busiest time of day. The Manager and Deputy are supernumary. All residents interviewed praised the staff team and the following comments were made: ‘The staff are very helpful. When it’s meal times they help you to the table and when you sit down they push your chair in for you.’ ‘The staff are lovely.’ ‘The staff always come and say: “Is there anything you need?”’ The home’s Administration Manager oversees staff recruitment. He told the inspector that staff are only employed in the home if they have satisfactory CRB/POVA checks. Staff records inspected confirmed this. This procedure will help to ensure that residents are safeguarded. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 18 Staff are well qualified and experienced. The Manager, Deputy, and one of the senior carers are nurses (although they do not carry out nursing care in the home as it is registered for care only). Over 50 of the care staff team have NVQ Level 2 or 3 in care. One member of staff told the inspector, ‘The training here is very good and the Manager encourages us to do courses.’ Regular staff meetings and supervision are carried out to give staff support and direction. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is excellent. Residents live in a home that is safe and well managed. This judgement has been made using available evidence including a visit to this service. (Standards 31, 33, 35, and 38 were inspected.) EVIDENCE: The Manager is responsible for the day-to-day running of the home. She has substantial experience in management and the care of older people with a variety of different needs. In discussion she demonstrated a commitment to providing quality care for residents in a homely and relaxed environment. One resident commented, ‘The Manager is very helpful and approachable.’ Residents’ view are collected in a number of ways. A board of governors oversees the home and make three formal visits to the home each year when they listen to residents’ opinions and write a report based on them. In addition, the Owning Body’s representative, who is based on site, calls into the home Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 20 every day and makes a popint of chatting to residnets about the home. An annual residents’ survey is carried out with the results printed and attached to the home’s statement of purpose. Residents are also asked for feedback on the home at residents meetings and kept informed of any new developments. Minutes from the most recent meeting (18.07.07) showed a good attendance of 13 residents and participants being informed about new staff, food hygiene training, and recent purchases (in this case roller blinds had been purchased for the residents who wanted them). Collecting residents’ views in these ways helps to ensure that the home is run in their best interests. Records showed that the health, welfare and safety of residents and staff is a priority in the home. Appropriate checks and servicing of equipment has been carried out, as has consultation with the home’s Fire and Environmental Health Officers. Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 21 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Agnes House DS0000036495.V341642.R01.S.doc Version 5.2 Page 24 - 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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