CARE HOME ADULTS 18-65
Agnes House 77-79 Newbury Lane Oldbury West Midlands. B69 1HE Lead Inspector
Jean Edwards Announced 17 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Agnes House Address 77-79 Newbury Lane Oldbury West Midlands. B69 1HE 0121 552 5141 0121 552 5141 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Alphonsus Homes None Care Home 5 Category(ies) of Learning Disability (5) registration, with number of places Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. All service users are accommodated at the home may also have physical disability 2. No service users who are wheelchair users are to be admitted to the home Date of last inspection 22/02/05 Brief Description of the Service: Agnes House is a small independent Care Home, which provides residential care for up to five younger adults with learning/physical disabilities. The two traditional detached bungalows, set in their own grounds are located on a main road in a mixed residential area. There is easy access to local amenities such as the leisure centre and public transport with links to towns such as Dudley, Oldbury and the Tesco shopping centre at Burntree. Externally the properties are generally well maintained, with limited car parking at the frontage and on the driveways of both bungalows. To the side and rear of the premises are gardens, with patios, lawned areas, trees and shrubs. The interiors of the bungalows strive to be domestic in style, promoting a homely environment whist providing a safe environment, they are maintained to high standards. The Home has a staff team of 26 people, with leadership provided by the recently appointed Acting Manager. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit was undertaken by the inspector from the Commission for Social Care Inspection using the following information and inspection methods: the previous inspection report, the action plan submitted in response by the home and records held at the home. The purpose of this visit was to monitor progress to meet the National Minimum Standards for Younger Adults. The visit commenced at 9:40 am and lasted until 4:50pm. During the visit the inspector spoke with the 5 residents who are currently living at the home. Longer discussions took place with 2 residents. Two senior staff took an active part in the inspection process and the majority of members of staff on duty were spoken with during the visit. The inspector toured the buildings, looking in particular at the kitchens, bathrooms, communal areas of the home and a sample of residents’ bedrooms, with their permission. What the service does well:
Residents are encouraged by staff to treat Agnes House as their own home and to be as independent as they wish. Two of the residents eagerly escorted the inspector to show off their own bedrooms, which are decorated and organised to their liking. Two people are able to voice their opinions. One person stated she “really liked living at Agnes House and being independent and still being able to visit her parents”. Another person commented that “the home and staff are very good”. The residents’ needs are continually reassessed and reviewed, with support sought from the relevant professionals to make sure that each person is able to develop their potential. People are able to attend daytime activities supported by the day care staff employed at Agnes House. Two people attend college courses and proudly showed off their certificates of achievements. Activities are geared to each person, with staff support provided from Agnes House. All residents are able to go on at least one annual holiday if they wish. One person has been to Gran Canaria already this year, other residents are planning their individual holidays, supported by volunteers from the staff group. Meals are provided individually for each person according to their likes and dislikes. Two of the residents do their own shopping and cooking, supported by staff. One person has decided to join Weight Watchers; trying to control her weight and she is being accompanied by a member of staff who is trying to do the same. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 6 There was a lot of friendly contact between staff and residents through out the day. During interviews staff demonstrated a dedicated approach to their work; they clearly know residents’ likes and dislikes and how to meet their needs. They answered questions in an open and honest manner. The home is clean, tidy and homely, whilst providing a safe environment. There is a programme of ongoing redecoration and replacement, which provides a pleasant environment maintained to high standards. This inspection was conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
A new record book has been introduced for each person called ‘ my world’, with an introduction called ‘ about me’. Picture formats are also being developed. The books are being developed to contain very detailed information and pictures to demonstrate how to communicate with each person. The home has also improved information sharing with each persons family or representative. There are also plans to seek advocates for the people who have little family involvement. A senior member of staff, was able to talk knowledgeably about how residents’ medication is managed and administered by the home, and was able to demonstrate that minor improvements have been put in place since the last inspection visit to make the medication system as safe as possible. A new refurbished and refitted kitchen was at the point of completion at 79 Newbury Road on the day of this visit. Improvements have been put in place to make the preparation of food as safe as possible, though the testing of food temperatures needs to be done on a more consistent basis. The home has not had a Registered Manager in place since September 2004 and there has also been a high turn over of staff. The acting manager commenced employment at Agnes House at the end of February 2005 and the staff team is now more stable, with improved selection and recruitment processes. This will help to provide residents with the continuity of support they require. The acting manager and the staff team are very committed to be involved in further training and personal development in order to provide an improved service for the people living at Agnes house.
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 7 There is now an improved level of support and monitoring of standards, with representatives from the organisation conducting unannounced visits on a monthly basis. Written reports of the findings are given to the home and sent to the Commission for Social Care 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.
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,4,5 No progress has been made to provide contracts/terms and conditions of occupancy for each person’s file this means that residents and their advocates do not have sufficient information regarding their rights and entitlements. Comprehensive assessment tools are used confirming that each person’s needs have been thoroughly assessed and there are assurances that their care needs will be met. Introductory visits and trial stays are encouraged by the home, making sure that people have time to make decisions which are right for them. EVIDENCE: On examination of a sample of residents’ files at the Home there is comprehensive assessment information and there is evidence of periodic reassessment as is good practice. The support of the speech and language therapist has been sought for one resident and staff are now using PECS (Picture Exchange System) as a means of communication. There is evidence that this is working well. Discussions with staff and examination of documentation offers some evidence that specialist services are accessed. Throughout this visit staff were seen to be communicating effectively with residents using methods, which are most suitable for each person, such as modified Makaton or pictures and symbols as well as the spoken word.
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 10 There are no copies of contract/statement of terms and conditions on any of the residents’ files. This is a previous requirement, which remains outstanding. There is no contractual evidence of the details of any agreed restrictions such as not going out unaccompanied or not smoking except in permitted areas. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,8,9,10 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet each person’s needs. The approach of a person centred planning process means that residents have as much control as possible over their lifestyle and care. Some areas of risk assessments require expansion, currently they do not cover all aspects of personal and social, and health care; this has the potential to place residents at risk. EVIDENCE: Each resident has a care plan in place, however not all of the sample of plans examined had been signed by the resident and/or their family or supporter. Where it is not meaningful for the resident to sign the care plan, the involvement of relatives or advocates must be sought. Discussions with two of the residents spoken with during this visit confirmed that they have an active involvement in developing and implementing their care plans. The structure and presentation of the plans is impressive, clearly detailing each persons individual needs, goals and aspirations. Examples are that one person aims eventually to live in a supported living environment. To this end the care
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 12 plan identifies the needs to improve budgeting skills; to improve travelling alone to visit parents; to improve computer skills and catering skills. This person attends college and has recently achieved an award for computer skills and is due to start a city and Guilds catering course in September 2005. Each persons Key-workers, link-workers and other professionals involved are identified in the plan. Behaviour management guidelines, triggers, cues and physical intervention techniques are documented together with comprehensive risk assessments. Though these must be expanded for each persons individual activities, particularly those undertaken outside the home. A protocol has been introduced for one person to encourage eating meals at the table and using ‘time out’ as reinforcement and all staff are encouraged to be consistent in their approach. There is evidence that the level and number of times physical intervention has not to be used for one person in particular; has significantly decreased. The acting manager has introduced systems to support and encourage staff to improve the detail in daily records to demonstrate the good practice in the way the residents needs are met. There is some evidence that records are more specific and focused on outcomes of areas identified as goals in the care plan. For example an entry described how one person was taken out for the day by two staff; to Wolverhampton and on to Telford using the bus and train. The person indicated he did not want to go bowling or ice-skating as planned, preferring to explore the park. An outing included eating out and it is noted that the persons eating habits have improved. Another persons daily notes recorded details of a spontaneous activity and reflection on skills used, such as social interaction with other people, travelling and money management skills. This improved style of daily records needs to be applied for all residents. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,14, 15,16, 17 Staff support residents to learn and use practical life skills, which encourages independence and enriches their lives. Social activities and stimulation has improved with revised staffing arrangements and as a result each person is able to enjoy social stimulation and follow their own hobbies and interests. The meals at Agnes House are good, offering both choice and variety and catering for any special dietary needs. EVIDENCE: There are structured activity programmes in place for each resident and these are flexible enough to allow spontaneous activities to be pursued. There is effective evaluation and monitoring of daily activities. The staffing structure has been reviewed and revised, with dedicated day-care staff employed by the home to support each persons social activities within the community. Some of the residents accommodated at Agnes House have conditions, which would not allow them to undertake paid, unpaid or voluntary employment opportunities. However there is ample evidence that all residents are encouraged and supported to improve their independent living skills.
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 14 A variety of activities were being pursued on the day of the inspection visit according to each persons interests and abilities; two people attended college courses, and three people went out on separate day trips. People are able to pursue a range of activities at Agnes House, these include the use of equipment in the newly refurbished quiet / sensory room and outdoor activities such as swing ball. One person mentioned that she used to be able to use a personal computer when she lived at home with her parents and would love to have the use of a computer again. Another person uses computers at college. The home needs to provide appropriate access for residents to use technology such as personal computers, faxes etc. to assist with their methods of communication and personal development. Each resident has a holiday arranged and funded by Agnes House, as part of the contract fee. The holiday arrangements are individual according to preferences and needs, the number of days away varies from 3 to 7 taking account of each person’s tolerance level. One person spoke about her holiday abroad earlier in the year and was looking forward to her next holiday. Each person receives support to access benefits and allowances, for example one person’s mother acts as his appointee, dealing with these matters, whilst other people receive support from social services departments. Four residents have active involvement with their families. One person goes to visit his family at their home twice each week. Another person receives family visits at Agnes House twice each week, with the development of home visits to his mother’s home continuing to prove successful. The third person visits his mother on a weekly basis. Support is available at some of these visits, members of staff stay throughout the visits if requested. A fourth resident visits her parents, with plans to independently. One resident has no family contact and currently does not have an advocate. The home has a range of weekly menus, which are varied, well balanced and nutritious. Meals and portion sizes eaten by each person are well-documented. The Home tries to ensure that each person has at least five portions of fruit or vegetables each day. Where possible residents are involved in shopping and preparing food. Two residents at 77, Newbury Road shop and prepare their own meals supported by staff. Individual choice of food and mealtimes is easily accommodated. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Personal support in this home is offered in such a way as to promote and protect resident’s privacy, dignity and independence. The health needs of residents are well met with generally good evidence of multi disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear and comprehensive arrangements in place to ensure residents’ medication needs are met. EVIDENCE: During the visit staff gave very thoughtful responses as to how they respected residents’ privacy and dignity and promoted their independence. Each person has a key worker and link worker, which enhances these aspects of care. Each person is encouraged to be as independent as possible, with two people taking responsibility for their own personal hygiene. There are detailed record charts identifying the level of support residents require with personal care. There are detailed health care records which demonstrate that the majority of health care checks are up to date. However the record of checks for SR was incomplete, the change of GP had not been noted and there was no evidence of the name of the audiologist or progress of the hearing test required. The home must update the information relating to SR regarding the change of GP,
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 16 the current optician and the current audiologist; making sure regular appointments are scheduled. The majority of residents use the services of health care professionals such as the NHS dentist, who makes visits to the home. This is less disruptive for residents. One person has recently had dental treatment under sedation at Sandwell Hospital. Residents generally have regular health checks, weight checks and continence assessments as needed. The home has comprehensive medication policies and procedures and all staff administering medication have received medication training provided by the organisation’s training section. A previous requirement to provide documentary evidence of accreditation of the training remains outstanding. There is a robust and rigorous medication system, which safeguards the residents with only minor improvements required at this visit. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has a satisfactory complaints system with evidence that staff understand the need to listen to and act upon areas of concern. Policies, procedures, guidance and staff training need to be implemented in order to provide residents with more safeguards from abuse. EVIDENCE: There have been no complaints recorded in the home’s complaints log since the last inspection visit in February 2005. There was evidence that each resident is made aware of how to raise concerns in a way most understandable to them. For example using the picture exchange system to explain how to complain. Residents who can communicate verbally stated that they feel that they can voice any concerns directly with their key worker, the manager or other staff at the home. The manager and staff are aware of the local authority multidisciplinary procedure for the protection of vulnerable adults. However no copies of this procedure could be found at the home. The manager needs to obtain copies of Sandwell and Dudley multi-agency Policies and Procedures for the Protection of Vulnerable Adults. All staff must be provided with appropriate levels of training to ensure that they are aware of and are able to respond appropriately to situations which require them to take action with the protection of vulnerable people. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26,27,28,30 The acting manager has a good understanding of the areas where the home needs to improve and proactive planning is now in place indicating how this improvement is going to be resourced and managed. The standard of the décor within this home is generally good with evidence of improvement through maintenance and future planning. The home presents as a homely and comfortable environment for residents. EVIDENCE: The residents at Agnes House, the majority of whom can display behaviours, which can challenge the service, have ample personal and communal space, with generally spacious bedrooms and quiet rooms. The internal decor is bright and cheerful, 79, Newbury Road has recently been redecorated. The Home provides a range of adapted equipment, suitable for the needs of people who have learning disabilities and may exhibit challenging behaviour. For example there are specially adapted units which can be closed down to protect electrical equipment such as high fi’s and TV’s and there is provision of a reinforced bed for one person and sensory equipment for another resident. Two of the residents were pleased to show the Inspector their individual bedrooms, confirming that they were able to have decor, furniture and possessions arranged to their own preference. However at least one person
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 19 does not have sufficient storage for clothing and did not have any lockable facilities in her room. The room has patio windows which open onto the garden but currently kept locked for security. The organisation must progress the replacement of the patio doors at 77, Newbury Road, with a replacement window, which can be opened for ventilation without giving rise to risks for absconding. There are a number of outstanding requirements from previous inspections which have yet to receive action particularly the restitution of the front driveway beyond the gates in an identified timescale. The acting manager indicated that meetings had taken place and that there are plans to complete the work within this financial year. The level of cleanliness in individual bedrooms, communal areas and kitchens were of a very good standard. The home now has two allocated motor vehicles, which are used to transport residents as and when needed, which improves access to community facilities. However, the increased number of residents and corresponding increase of members of staff, off-road car parking is even more limited. The organisation needs to consider the feasibility of changing the front driveways to both properties to provide adequate car parking facilities. The acting manager is making progress to make sure that there is regular maintenance to the garden areas, reorganising the areas and trimming shrubs to provide a safe and attractive recreational area for the residents to use. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35,36 Good progress has been made in addressing substantive staffing levels and now residents generally receive consistent care. Recruitment and selection processes are now more robust and provide improved safeguards to offer protection to people living in the home. EVIDENCE: There is a small stable core group of long serving staff, though there have been a further 12 resignations since the last inspection visit in February 2005. These have been for a variety of reasons and the high turnover of staff now seems to be resolving. There are currently vacancies for 4 weekend care officers and 1 vacancy for a night worker. Recruitment is taking place, interviews and satisfactory clearances awaited. Assessment of the staffing rotas submitted as part of the pre-inspection information and current working rotas provided satisfactory evidence that the home is adequately staffed to meet the residents’ needs. Staffing rotas have been revised, and new roles introduced to provide consistency with day care and personal development opportunities for residents by staff employed by Agnes House.
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 21 There are now records for all staff working at the home. These were well organised and contain an improved level of the information needed to make recruitment and retention processes robust. Members of staff interviewed felt that there is an improved level of communication with the introduction of verbal handovers at each shift change, senior staff meetings taking place weekly and general staff meetings taking place on a monthly basis. The agenda is displayed two weeks prior to each meeting and minutes of meetings are also displayed, with staff expected to sign them to demonstrate that they have read them. Staff were knowledgeable about residents needs and demonstrated a friendly and appropriate rapport with the residents. The home is making good progress to meet requirements issued at previous inspection visits relating to staff training. The acting manager has introduced an induction programme provided by an accredited Learning Disability Awards Framework provider. The home is making good progress towards achieving a 50 target of care staff with an NVQ 2 or LDAF equivalent by the end of 2005. Currently there are five members of staff with NVQ level 2 or three, to staff who have completed the LDAF award and 15 members of staff registered to undertake training to achieve the LDAF award. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,41,42,43 The acting manager is supported well by the senior staff in providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. Improved monitoring arrangements have resulted in practices which now provide safeguards to the health, safety and well being of persons using the service. EVIDENCE: The acting manager has been in post since the end of February 2005 and has submitted an application to be registered with the CSCI. This is currently being processed with provisional date given at this inspection for a ‘fit person’ interview to complete the process. The majority of staff have received fire safety training within the last six months, with other mandatory training dates planned for all staff. However the organisation needs to be aware that training quickly becomes diluted when
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 23 there is a high staff turnover. The organisation must provide ALL staff with updated mandatory training, including: basic first aid and infection control. There are a number of monitoring arrangements in place including unannounced monthly visits, now recommenced on a more consistent basis from the organisations, nominated representative with reports which are given to the home and copied to the CSCI. A sample of fire safety and maintenance service records were examined, these were generally satisfactory, with minor improvements required. For example the home’s fire risk assessment was not available at this visit. There is currently no asbestos risk assessment, however the manager has plans to devise and implement a policy risk assessment to address this. The acting manager also plans to label all new electrical appliances with the date of purchase to ensure that a prompt portable electrical appliance test is carried out, which is good practice. There were a number of issues identified at the previous inspection visit, which have subsequently been improved in relation to health and safety. There was just 1 recorded accident involving a resident and 3 recorded accidents involving members of staff since the visit in February 2005, and there is evidence that a regular accident analysis has taken place. Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 2 Standard No 22 23
ENVIRONMENT Score 4 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x 3 2 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 2 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 4 3 2 3 Standard No 31 32 33 34 35 36 Score x 2 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Agnes House Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 2 2 E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 5 Regulation 5 Requirement To ensure that there is a copy of the costed contract / terms and conditions, appropriately signed and dated retained on each person’s case file. (Timescale of 31/03/04 not met) To ensure that there are comprehensive documented risk assessments and risk management strategies in place for all activities for each resident To provide appropriate access for residents to use technology such as personal computers, faxes etc. to assist with their methods of communication and personal development To update the information relating to SR regarding the change of GP, the current optician and the current audiologist; making sure regular appointments are scheduled To provide documentary evidence of accreditation of medication training, to be submitted to the CSCI satellite office, Halesowen (Timescale of 31/03/04 not met) To clarify as prescribed
Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 26 Timescale for action 31/07/05 2. 9 13(4) 31/07/05 3. 16 16(2)(a) (m) 30/08/05 4. 19 17(1) Schedule 3 (3) 31/07/05 5. 20 13 (2) 30/06/05 dosages with the prescriber and /or the pharmacist To ensure that any written changes to prescribed medication on the MAR sheets is signed and dated. To obtain copies of Sandwell and 30/06/05 Dudley multi-agency Policies and Procedures for the Protection of Vulnerable Adults To progress the replacement of 31/07/05 the patio doors at 77, Newbury Road, with a replacement window, which can be opened for ventilation without giving rise to risks for absconding To provide additional storage for clothing and personal possessions for SR and any other resident where storage facilities are insufficient To provide lockable facilities for the residents bedrooms at 77, Newbury Road To progress restitution of the front driveway beyond the gates, which has been risk assessed, in an identified timescale (Timescale of 31/03/04 not met) To complete the resurfacing of the front drive to an acceptable standard. (Timescale of 31/03/04 not met) To provide regular maintenance to the garden areas, e.g. weeding, trimming shrubs etc. to ensure that they are safe and attractive. (Timescale of 31/03/04 partly met) To consider the feasability of changing the front driveways to both properties to provide adequate car parking facilities 6. 13(4) 23 7. 13(4) 23(2) 23 26 8. 24 23(2) (a-e) 31/08/05 9. 24 23(2)(o) 31/08/05 Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 27 10. 42 5 23(4) To include smoking arrangements (SH): - In the resident’s individual contract - On the Home’s Fire Risk Assessment (Timescale of 31/03/04 not met) To ensure that all high risk cooked food temperatures are consistently checked and documented (Timescale of 31/03/04 not met) To ensure that there is an up to date Fire Risk Assessment for the home, available for inspection 30/06/05 11. 42 18(1)(c) 12. 43 25 13. 43 25 To provide ALL staff with updated mandatory training, including: basic first aid and infection control To develop a business and financial plan, forwarding copies to the CSCI Area Office for consideration (Timescale of 31/03/04 not met) To send a copy of the last years audited accounts for Agnes House to the CSCI satellite office, Halesowen (Timescale of 31/03/04 not met) 31/07/05 30/06/05 30/06/05 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. Refer to Standard 6 23 Good Practice Recommendations That individual care plans are signed where it is meaningful for residents to do this, for example SR That advocacy support is sought for MT and that the Sandwell Advocacy Service is contacted to resume support
E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 28 Agnes House 3. 4. 5. 33 34 34 for SG That the Organisation negotiates to obtain additional funding from the placing authority for additional day activities SH. That copies of public liability insurance and CRB clearance from the private Chiropodist is obtained - partly met That the reasons given for any gaps in employment histories are recorded Agnes House E55 S4783 Agnes House V220269 170505 Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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