Inspection on 02/05/06 for Agnes House

This inspection was carried out on 2nd May 2006.

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

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

Other inspections for this house

Agnes House 15/08/07

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 Keith Charlton Unannounced Inspection 2nd May 2006 09:30 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.V292209.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V292209.R01.S.doc Version 5.1 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 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.V292209.R01.S.doc Version 5.1 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 15/9/2005 2. Date of last inspection Brief Description of the Service: Agnes House is registered under the Care Standards Act 2000 and has been providing care since 1992. Agnes House is a purpose built home set in five acres of landscaped gardens in the centre of Leicester. It is registered for twenty six service users within the categories of old age, not falling within any other category, physical disability and sensory impairment. Accommodation is on two floors and these can be accessed by a shaft lift. The home offers a large lounge-dining area on the ground floor, which leads to a large well-fitted conservatory and this leads into a sensory garden. A further lounge is situated on the first floor. All the bedrooms offer en-suite facilities and all rooms are served by an emergency call system. The home enjoys the facilities and activities offered by William House, a sheltered housing scheme that is built adjacent to the home. These facilities include a chapel, Library and large meeting room. The maximum weekly fee is £440 – this information was provided in the week of the Inspection. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service user and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager and Deputy Manager were on duty. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection by the home since the last inspection. There have been no complaints regarding the service since the last inspection. The Inspection took place between 9.30 and 16.45 and included a tour of the building, inspection of records, discussion with the Registered Manager and direct and indirect observation of care practices. The Inspector spoke to eight residents, three members of staff and two relatives. What the service does well: Service users felt that they were central to the running of the service - they said that staff were friendly and caring, the food was good and plentiful and that they are given a choice for each mealtime, that they could approach staff or Management if they had a concern and were confident it would be sorted out, activities are organised, and visitors are made welcome – this was also confirmed by relatives. Service users again said they liked their bedrooms and they could bring in their own things and they liked the garden and conservatory. They said that they are encouraged to retain their independence and are supplied with equipment to assist them. Staff were again observed to be friendly and respectful towards service users. Relatives spoken to said that the service was of a very high standard and said staff and management were very friendly. Staff said that they are asked to read service users Care Plans and the Policies and Procedures of the home so that they aware of service users needs and are consistent in their work. Staff were aware of the whistle blowing procedure in Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 6 case of abuse. They felt valued by Management in providing good care to service users. 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. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 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.V292209.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an assessment system in place to ensure that staff can deliver an appropriate service. EVIDENCE: A service user said that she could remember being asked questions about her needs before she was admitted to the service. She thought that this would assist staff to look after her. At the time of the inspection the Registered Manager went to a hospital to assess a person applying to be a service user. Assessments were looked at and were found to contain an initial assessment of need regarding physical, medical and social needs. These were undertaken by an appropriate person. The service does not offer intermediate care services. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are generally looked after well in relation to their health and care needs. EVIDENCE: Service users differed in their views of the existence of Care Plans. Some stated that they knew that there was one and they had signed it – others said they had never heard of a Care Plan. The Care Plans viewed had evidence that service users had signed to state that they were in agreement with the care detailed in Care Plans. The Registered Manager said she would remind service users that there were Care Plans and they could see them at any time. Care Plans were generally detailed and include Risk Assessments regarding identified areas of risk though some sections did not have detail as to when some checks, dental and optical, needed to be arranged. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 10 Care staff members spoken to said that they were encouraged by management to read all service users Care Plans. Service users said that if they were unwell and wanted to see a GP staff would arrange this. There was ample evidence on service users files as to medical appointments being arranged. Some service users said that they were taking care of their own medication, which helped them feel independent. Others said they were glad that staff kept it and gave it to them. Staff said that only senior management issued medication. The Deputy Manager said that senior management were either Registered Nurses or had attended pharmacy training in the administration of medication. Manager issuing records were checked and found to be of a generally good standard. Service users thought staff carried out personal care in a way that respected their privacy and dignity. Staff were observed to be friendly and respectful to service users. Relatives also highly praised staff for their friendly care. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lead full and active lifestyle and can exercise choice. EVIDENCE: Service users spoken to said that they thought that the current level of activities was good and they were looking forward to having more outings this summer. Service users said there were a number of activities – nationality days (England Day, Scotland Day etc), games afternoons, quizzes, making cards for Easter, pottery painting etc. Records confirmed service users participation in activities. A service user spoken with said she goes to a day centre and wanted to go to another one – the Registered Manager is to follow up this request. Another service user said that she was responsible for watering the pot plants in the home and obviously was pleased to be able to carry out this task. There was a discussion with the Registered Manager as to alert staff to service users previous interests and hobbies so that staff can use this as a basis to encourage conversation. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 12 A Holy Communion Service is held in the home weekly; in addition to this a Church service is held on a weekly basis in the Chapel in the adjoining flats, which service users can attend if they choose. Service users said that there were no rules and they could please themselves about things – getting up and going to bed times etc and that staff encouraged them to retain their independence. A service user is encouraged to get up and go to bed at certain times due to the long length of her sleeping pattern. The Registered Manager said this arrangement would be agreed with her and be part of the Care Plan. The Inspector sampled the mid-day meal. The quality of the food was good, and the meat dish and desserts were home made using fresh ingredients. Choices for both the main course and dessert were available. All service users spoken with confirmed that all meals were of a good quality and were enjoyed. The Registered Manager said that a cooked breakfast was available on request and she would remind service users of this choice. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users/their representatives can be confident their concerns will be properly attended to. EVIDENCE: Service users again said that they would have no hesitation about going to Management if they had a problem and were confident it would be properly sorted out. There is a detailed Complaints Procedure displayed on the Notice Board. The Registered Manager said there had been no complaints received since the last inspection. There is no central complaints book to record information at present – the Registered Manager said this would be followed up. The Commission for Social Care Inspection has also not received any complaints regarding the service since the last inspection. Staff spoken to knew to take their concerns further if abuse was suspected and are now aware of outside Agencies to go to if no action was taken by the service. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The facilities of the service are homely and comfortable. EVIDENCE: Service users all said that they liked their bedrooms and they could bring in their own furniture. The well maintained garden and large conservatory were also appreciated. Facilities were found to be clean and generally odour free. Service users said that this was always the case. The Registered Manager is to look at replacing a bedroom carpet due to continence issues. There is a maintenance programme and the Registered Manager said that three bedrooms were to be refurbished this year and that scuffed paintwork seen in some bedrooms would be attended to. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current staffing levels may lead to service users’ needs not being met though other staff systems – recruitment and training - are fully in place. EVIDENCE: There were again comments from service users that staff were usually busy as there were a number of service users who needed more care and this meant longer waits for care. Staffing levels generally meet the Requirements of the Commission for Social Care Inspection. However, at times, the staff rota indicated morning shifts with four care staff and afternoon shifts with three care staff on duty (plus a senior in charge for these shifts) for twenty six service users accommodated. This may stretch staff resources when dealing with service users needing two staff to assist. The Registered Manager stated that staffing levels have not been reduced but agreed that they would again be reviewed to ensure that service users needs are fully met. Some staff records were inspected. They were found to contain all statutory checks needed to ensure protection for service users. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 16 Staff said that training was regularly provided. Records showed they have now received training to cover service users health needs. There is an ongoing training programme and evidence produced as to staff undertaking essential courses. Staff also outlined a number of training courses that they have attended and that they were encouraged to enrol on National Vocational Qualification level 2 courses. The Registered Manager stated that when four staff complete their National Vocational Qualification level 2 courses then the service will have achieved the National Minimum Standard of 50 of staff with this training. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration systems are generally in place. Health and Safety systems protect the welfare needs of service users. EVIDENCE: All parties spoken to – service users, staff and relatives said that there was organised and effective Management of the service. This situation is commended. There is a Quality Assurance system in place. This is carried out on a yearly basis to ensure that the service is effective in meeting service users needs and wishes. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 18 The Registered Manager recognised that staff supervision was behind schedule and she was seriously considering partly delegating this task to the Management team to ensure this is in place to support staff. Service users said that they felt safe in the home. Staff were observed to be following proper Moving and Handling techniques. Staff said that they had received Health and Safety training and this was indicated in the training records. There were written Risk Assessments for safe working practices. The frequency of fire drills now meets the requirement of three monthly. Night staff have now been included in fire training. Records indicated regular emergency lighting and fire bell testing. The staff spoken to had a generally good awareness of the fire drill procedure. A fire risk assessment was seen and the Registered Manager said this was reviewed on a yearly basis. Here are radiator covers to protect service users from burning and the hot water temperature was within the limits of the National Minimum Standard. Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 19 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X X 3 Agnes House DS0000036495.V292209.R01.S.doc Version 5.1 Page 20 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.V292209.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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