CARE HOME ADULTS 18-65
Agnes House 77 - 79 Newbury Lane Oldbury West Midlands B69 1HE Lead Inspector
Mrs Jean Edwards Unannounced Inspection 26th October 2005 09:40 Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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 DS0000004783.V260896.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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 ayneshouse@hotmail.com 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) Alphonsus Homes Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. All service users accommodated at the home may also have a physical disability No service users who are wheelchair users are to be admitted to the home 17/05/05 Date of last inspection 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 Manager. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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. An evaluation and judgments have been reached using the following information: the previous inspection report, the action plan submitted in response by the home and records held at the home. The purpose of this visit is 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 had some communication with residents who are currently living at the home. Longer discussions took place with one resident. 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. A brief tour of both bungalows has taken place, looking in particular at the kitchens, bathrooms, and communal areas of the home and a sample of residents’ bedrooms, with their permission. What the service does well:
Members of staff encourage residents to treat Agnes House as their own home and to be as independent as they are able to be. One person has allowed her own bedroom to be viewed. This has been decorated and organised to her preference. This resident is able to share her opinions, stating that she “really enjoys living at Agnes House and being able to be independent. People are generally able to attend daytime activities supported by the day care staff employed at Agnes House. One person continues to attend college courses and is proud of her achievements. Activities are geared to each person, with staff support provided from Agnes House. All residents have been able go on one or more holidays, according to their wishes and abilities to cope. Meals are provided individually for each person according to their likes and dislikes. Usually two of the residents do their own shopping and cooking, supported by staff, however one person is currently in hospital. There has been generally good communication and rapport between staff and residents throughout this visit. During discussions staff have demonstrated a dedicated and committed approach to their work. The established core group of staff clearly know residents’ likes and dislikes and how to meet their needs. They have answered questions in an open and honest manner. The home is clean, tidy and homely and generally provides a safe environment. There is a program of on-going redecoration and replacement, which maintains a pleasant environment.
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 6 This inspection has been conducted with full co-operation of the Manager, staff and residents. The atmosphere through out the inspection has been cooperative and friendly. What has improved since the last inspection? What they could do better:
The registered person must make sure that the most recent inspection reports from the CSCI are readily available at all times, so that members of staff, families and any other interested people can have information about the homes performance. At previous inspection visits there has been a requirement for all residents and their families or their representatives to be provided with a revised contract / terms and conditions by the organisation, and for copies of these documents to be available in the home. This requirement remains outstanding and must now be actioned as a priority. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 7 The home must make significant improvements to the records it keeps to demonstrate the care given to the residents. As indicated at the previous inspection visit, although there are fuller details in one persons daily records, all daily records must contain this level of detail. Information relating to the newest resident must be improved with consistent records of appointments and reviews with other healthcare professionals, such as dentists, chiropodists, audiologists and opticians. In addition there must be accurate records available to show that each persons weight is monitored regularly and their food intake is recorded. The registered provider must give serious consideration to providing appropriate access for residents to use technology such as personal computers, faxes etc. to assist with their methods of communication and personal development. At the previous inspection visit a requirement was made to improve the Medication Administration Records (MAR) sheets so that there is an accurate record to show that residents have received their medication at the prescribed times or all that there is a record of the reason for non-administration. This improvement has not been made. As indicated at the previous inspection there must be improvements relating to policies, procedures and staff awareness particularly about the protection of vulnerable people from abuse, offering more safeguards to protect the residents living at this home. Only limited progress has been made for all staff to receive the refresher training sessions that they need to be aware of and meet the needs of the residents. The registered person must make sure that all allegations of abuse or suspected abuse are reported immediately in accordance with the Sandwell multi-agency policy for the protection of vulnerable adults. The registered person must put measures in place to provide all staff with training how to respond to challenging and aggressive behaviour as a priority. This must happen to protect residents and staff from risks of harm. The front driveways need to be resurfaced to be safe and thought needs to be given to provide adequate numbers of off road car parking spaces. The requirement to improve the driveway has been outstanding for a considerable time. There are plans to replace the heavily stained carpets in the communal areas at 79 Newbury Lane; these must be actioned within an identified timescale. The registered person must make sure that all furniture, especially dining chairs are suitable for the group of people living at the home, that they are sound construction and have fire retardant coverings. The home has continued to experience difficulties in retaining and recruiting sufficient numbers of appropriate people. This is a matter of serious concern and the registered person has been required to maintain adequate staffing levels with sufficient numbers of trained, experienced, competent staff, with
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 8 immediate effect. There are additional serious concerns about recruitment practices at the home. For the second time since February 2005 staff have been allowed to commence employment at the home without satisfactory checks and clearances and appropriate documentation. The registered person has been required to put additional safeguards in place with immediate effect and give assurances to the CSCI that the situation will not be allowed to occur again. There has been a recent change to the management arrangements at Agnes House, with the manager spending significant amounts of time on the development of new projects within the organisation. Although there are delegated contingency management arrangements in place the CSCI were not made aware of them. The registered person must notify the CSCI office, Halesowen of any changes to the management arrangements for the home, including cover arrangements and contingency plans, without undue delay. There are a number of areas including record keeping and monitoring of accidents and incidents, which have deteriorated since the last inspection in May 2005. Arrangements must be put in place to improve all areas of record keeping, to reintroduce monitoring arrangements and to safeguard all residents and staff. 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 DS0000004783.V260896.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 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. This is a long-standing requirement, which must be actioned. EVIDENCE: Although it is evident from discussions with staff that they are aware of the content of the previous inspection report, the actual document was not easily available at the home. This meant that senior staff are not always aware of the areas, which need to improve. The registered person must ensure that the most recent inspection reports are readily available in the home at all times. The requirement issued at previous inspection visits 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, is not met. This is a long-outstanding requirement, which must be actioned as priority. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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 the following standard(s): 6,7,9 There is a clear and consistent care planning system in place providing 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. Risk assessments have been expanded since the last inspection visit to cover all aspects of personal and social, and health care; this has the potential to place residents at risk. EVIDENCE: The structure and presentation of the residents care plans is generally very good, with detailed individual needs, goals and aspirations. These include goals to improve social skills, communication skills and for one person the aim to eventually live independently, in a supported environment. This resident is continuing to practice budgeting skills and travelling alone to visit parents, especially as they plan to move house some distance away. Discussions with this resident during this visit confirmed her active involvement in developing and implementing her care plan. She is happy to share and discuss her care plan records as part of this visit. The home has made progress for residents the resident to sign their care plan where it is
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 12 meaningful for them to do so. There is evidence that pro-active involvement of relatives or advocates for support of other residents is being sought. Behaviour management guidelines, triggers, cues and physical intervention techniques are documented together with comprehensive risk assessments. These have been expanded for each persons individual activities, particularly those undertaken outside the home. At the previous inspection visit there was evidence that the level and number of times physical intervention used for one person in particular had significantly decreased. However the number of recorded incidents of challenging behaviour, including violence towards staff has recently significantly increased. There are 20 documented incidents from mid-September to mid October 2005. There has been a high staff turnover in the past 12 months and may be a factor in the escalation of incidents of challenging behaviour. Key workers and teams have changed a number of times; in fact there has been a complete change of night care staff. It is well recognised that this home that the young adults accommodated need continuity in their daily regimes and they need to know their carers. The progress to make sure that records are more specific and focused on outcomes of areas identified as goals in the care plan has been diminished by the continual turnover of staff. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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 the following standard(s): 16 Social activities and stimulation has decreased with inadequate staffing arrangements and as a result each person is not able to participate in appropriate social stimulation to follow their own hobbies and interests and developed their personal potential. EVIDENCE: The majority of these standards were assessed at the previous inspection visit. The home continues to provide day-care opportunities on an individual basis for each of the residents. However the placement authorities are not funding the staffing levels required for each person to access community facilities. The situation is compounded by the continual staff turnover, which does not allow relationships and effective risk management strategies to be established. The previous requirement 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, remains outstanding. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 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 have deteriorated and there are insufficient assurances to ensure residents’ medication needs are met. EVIDENCE: At the previous visit a requirement was made to update the information relating to SR regarding the change of GP, the current optician and the current audiologist; and to make sure regular auditory appointments are scheduled. On examination of SRs case file, some information had been updated, however some of the records are inconsistent. Staff state that accessing appointments are problematic and the resident has not yet received an appointment. It is felt that her hearing impairment combined with the changes in staff personnel may be contributing to an escalation of challenging behaviour. The residents generally have regular health checks, weight checks and continence assessments as needed. However an examination of SHs health care records highlighted that there are no records of weight monitoring since May 2005. The registered person must ensure regular monthly monitoring residents weights is resumed. Seniors admitted that staff turnover, with the
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 15 need for induction and supervision have resulted in diminished time for monitoring that all recording by staff is satisfactory. For example daily food diaries are not completed every day, there are gaps where no meals are recorded and some days are blank with no entries (SH). 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. The requirement issued at previous visits to ensure that the Medication Administration Records (MAR) sheets are maintained without gaps has not been actioned. There were gaps on the MAR sheets for SR at 77 Newbury Lane and for SH and KH at number 79 Newbury Lane. This means there is no assurance that that medication is signed for immediately after medication is administered or an appropriate code is entered to indicate the reasons for non-administration. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home has a comprehensive complaints system with limited evidence that staff understand the need to listen and to act upon areas of concern. Policies, procedures, guidance and staff training have not been appropriately implemented in order to provide residents with safeguards from abuse. EVIDENCE: The home has a comprehensive complaints procedure, produced in a pictorial format. The complaints log indicates one recent complaint made by a member of the public about perceived behaviour by members of staff escorting a resident in a public place. Although the complaint has been investigated internally by the home and appropriate action appears to have been taken with the member of staff, the incident was not reported in accordance with multiagency adult protection procedures. Additionally there have been two allegations made by resident, which were later withdrawn but have not been reported in accordance with the multiagency adult protection procedures. None of the incidents have been reported to the CSCI to comply with notification is required by Regulation 37. The registered person must ensure that all allegations of abuse are reported immediately in accordance with the Sandwell multi-agency policy for the protection of vulnerable adults and in compliance with The Care Homes Regulation 37.2 During the visit episodes of physically challenging behaviour from SH have occurred towards young female members of staff, requiring the intervention of senior male care staff. Discussions with staff and examination of SHs case records provided evidence of escalating episodes of challenging behaviour of
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 17 the sexual and repetitive nature. There have been 20 recorded incidents of challenging behaviour from SH between 1 - 26 October 2005, some resulting in minor injuries to staff, particularly female staff. The need for consistent risk management strategies is being greatly hindered by the high turnover of staff and there is insufficient evidence to show that all staff have received up to date approved/accredited physical and non-physical intervention training. The homes policies and procedures relating to the protection of vulnerable adults are dated February 2003. All policies and procedures must be reviewed at least annually. It is strongly advised that the registered person contacts Sandwells Adult Protection Coordinator, with a view to accessing approved upto-date training relating to the protection of vulnerable adults for all staff. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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 the following standard(s): 24 The standard of the décor within this home is generally good with evidence of improvement through ongoing maintenance. The home generally presents as a safe, homely and comfortable environment for residents. EVIDENCE: The majority of the standards relating to the environment were assessed at the previous inspection. During the brief tour of both bungalows there is evidence that the physical environment is generally being maintained satisfactory standards. Staff stated that there are plans to replace the heavily stained carpets in the communal areas at 79 Newbury Lane. During the visit at least two of the dining chairs are unsafe to sit on. The maintenance person repaired a number of the dining chairs during the visit. Staff state that the recently purchased chairs have been replaced on one occasion, to date. The dining furniture, especially the dining chairs must be suitable for the group of people living at the home, they must be sound construction and have fire retardant coverings.
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 19 A sample of residence bedrooms have been viewed with their permission, they are attractively decorated, with personal possessions and equipment suited to each persons tastes and needs. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34 There is an extremely high staff turnover, the previous good progress to stabilise substantive staffing levels has declined and residents do not receive consistent care. Recruitment and selection processes have seriously deteriorated and do not provide satisfactory safeguards or offer protection to people living in the home. The results of the strong commitment to training are diminished due to the high staff turnover. EVIDENCE: From assessment of staffing rotas and discussions with the manager and senior staff it is evident that there continues to be a high staff turnover. Since the last inspection visit in May 2005 there has been a complete change in staff personnel working nights at the home. Approximately 15 staff have left the homes employ between May and October 2005, the total in excess of 27 staff leaving the homes employ since February 2005. Currently there are eight staff vacancies, not including two staff on maternity leave and one person on long-term sick. In addition it is stated that these numbers do not take account of staff that have commenced and left employment in a short period of time. The home is not currently using agency staff; staffing levels are being maintained by existing staff. There is evidence of staff; particularly seniors working hours well in excess of the EU work time directive over sustained periods of time. An immediate requirement has been issued at this visit to maintain adequate staffing levels with sufficient numbers of trained, experienced, competent staff, with immediate effect. The registered person
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 21 must seek advice from the Local Authority Environmental Health Officer relating to the risks to staff well being and health and safety related to the excessive hours being worked. The organisation has robust recruitment procedures, however from the assessment of a sample of staff files it is evident that staff have continued to be employed without satisfactory clearances and documentation in place. Out of the nine most recently appointed staff, seven did not have an appropriate CRB clearance and three did not have any POVA clearance. There was insufficient evidence that POVA/CRB checks had been commenced prior to the persons employment. This situation is viewed with extreme seriousness by the CSCI, especially as this issue was highlighted at the unannounced inspection February 2005, resulting in immediate requirements and a serious warning letter to the registered person at that time. Further immediate requirements have been issued at this inspection visit. In addition there was insufficient documentary evidence on staff files of recent photographs, proof of identity, and satisfactory references. The registered person is required to ensure that no further persons commence employment at Agnes House until All satisfactory clearances have been received in compliance with the Care Homes Regulations 2001, Schedules 2 and 4, including satisfactory POVA /CRB clearances and 2 satisfactory written references. The registered person has been required to ensure that the four staff without a documented POVA first clearance are given leave and do not attend Agnes House or work any further shifts until a documented POVA clearance is received. In addition the registered person is required to consult the CSCI satellite office, Halesowen in any exceptional circumstances to allow the employment of persons on a POVA first basis, providing evidence of rigorous pre-employment checks, a documented risk assessment. There is evidence that disciplinary action has been taken with members of staff, however no regulation 37 notification has been made to the CSCI. It is strongly advised that exit interviews are conducted to identify reasons and trends for high staff turnover. The organisation continues to provide a strong commitment to staff training and development. It is evident from discussions that staff value training and development opportunities. However the continued detrimental effect of the continual staff turnover is causing a heightened level of stress and pressure on the core group of highly committed staff and diminishes the outcomes of training and supervision. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 The manager is supported well by the senior staff in providing clear leadership throughout the home, though the continually changing staff group do not satisfactorily demonstrate an awareness of their roles and responsibilities. Previously improved monitoring arrangements have fallen due to the instability of the staff team, resulting in practices, which now do not provide adequate safeguards to the health, safety and well being of persons using the service. EVIDENCE: There have been changes to the management of Agnes House, the current manager, Jason Lane, has been in the post since February 2005. He has recently been successful with the CSCI registration process. However it emerged during this visit that the manager has spent a significant amount of time involved in the commissioning of other establishments within the organisation. Some of the managerial responsibilities for Agnes House have been delegated to one of the experienced senior care officers for parts of each week. The changes to the management arrangements have not been notified to the CSCI and there was no indication on staffing rotas that the manager had
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 23 spent time elsewhere. The manager states that his involvement with the new developments will end shortly. The registered person must notify the CSCI office, Halesowen of any changes to the management arrangements for the home, including cover arrangements and contingency plans, without undue delay. There has been a general deterioration in the standard of record keeping across a number of areas, such as those already mentioned: medication, food diaries, weight records and staffing records. There are also failures to make notifications to the CSCI office, Halesowen in compliance with Regulation 37. Accident records of the home cannot be properly audited at this visit. Some accident records are not fully and accurately completed. Furthermore the senior member of staff has not had sufficient dedicated time to undertake a recent up-to-date documented accident analysis or to undertake an up-to-date analysis of incidents / challenging behaviours for each resident. Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 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 2 X X X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score 2 X 1 1 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Agnes House Score X 2 2 X Standard No 37 38 39 40 41 42 43 Score 2 2 2 X 1 2 2 DS0000004783.V260896.R01.S.doc Version 5.0 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 2 Standard YA1 YA5 Regulation 5(1)(d) 5(1)(b)(c) Requirement To ensure that the most recent inspection reports are readily available at all times 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 and 31/07/05 Not Met) 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 (Timescale of 30/08/05 Not Met) 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 (Timescale of 30/08/05 Not Fully Met) 1) To resume regular monthly monitoring residents weights, especially SH Timescale for action 01/12/05 01/12/05 3 YA16 16(2)(a) (m) 01/01/06 4 YA19 17(1) Schedule 3 (3) 01/12/05 5 YA19 12(1)(a) 01/12/05 Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 26 6 YA20 13(2) 2) To ensure daily food diaries are fully and accurately completed To provide documentary evidence of accreditation of medication training, to be submitted to the CSCI satellite office, Halesowen (Timescale of 31/03/04 and 30/06/05 Not Met) To clarify as prescribed dosages with the prescriber and /or the pharmacist (Timescale of 30/06/05 Not Fully Met) To ensure that any written changes to prescribed medication on the MAR sheets is signed and dated (Timescale of 30/06/05 Not Fully Met) To ensure that the Medication Administration Records (MAR) sheets are maintained without gaps; and ensure that medication is signed for immediately after medication is administered or an appropriate code is entered for nonadministration To ensure that all allegations of abuse are reported immediately in accordance with the Sandwell multi-agency policy for the protection of vulnerable adults To retrospectively report the three recent allegations; one relating to MT and two relating to SG, investigated internally, to the appropriate agencies The registered person must ensure that policies and procedures relating to the protection of vulnerable adults be reviewed at least annually and demonstrate linkage with the multi-agency adult protection procedures
DS0000004783.V260896.R01.S.doc 01/12/05 7 YA20 13(2) 01/12/05 8 YA23 13(6) 26/10/05 9 YA23 13(6) 26/10/05 10 YA23 13(6) 01/12/05 Agnes House Version 5.0 Page 27 11 YA23 13(6) 12 YA24 23(2) e) (a- The registered person must 01/12/05 contact Sandwells Adult Protection Coordinator, with a view to accessing approved upto-date training relating to the protection of vulnerable adults for all staff 1) To progress restitution of the 01/01/06 front driveway beyond the gates, which has been risk assessed, in an identified timescale (Timescale of 31/03/04 and 31/08/05 Not Met) 2) To complete the resurfacing of the front drive to an acceptable standard. (Timescale of 31/03/04 and 31/08/05 Not Met) 3) 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 and 31/08/05 Not Fully Met) To consider the feasibility of changing the front driveways to both properties to provide adequate car parking facilities (Timescale of 31/08/05 Not Met) 1) To progress the planned replacement of the heavily stained carpets in the communal areas at 79 Newbury Lane 13 YA24 23(2)(o) 01/01/06 14 YA24 23(2)(d) 01/12/05 15 YA33 18(1)(a) 2) To ensure the dining furniture (especially chairs) are suitable for the group of people living at the home, that they are sound construction and have fire retardant coverings 1) To maintain adequate 26/10/05
DS0000004783.V260896.R01.S.doc Version 5.0 Page 28 Agnes House staffing levels with sufficient numbers of trained, experienced, competent staff, with immediate effect 2) To ensure that any member of staff choosing to work excessive hours has a written risk assessment undertaken and the management of the Home must consult with Environmental Health Services to ascertain their view of the health and safety risks to staff. 19(1)(4)(5) The registered person is 26/10/05 required to ensure that no further persons commence employment at Agnes House until All satisfactory clearances have been received in compliance with the Care Homes Regulations 2001, Schedules 2 and 4, including satisfactory POVA /CRB clearances and 2 satisfactory written references, one of which should be from the current or previous employer, with immediate effect. 13(6) The Registered person is 19(1)(4)(5) required: 1) To ensure that POVA/CRB applications are completed and sent to the Criminal Records Bureau to obtain clearances, within 48 hours. 2) To ensure that any person currently employed at Agnes House without a POVA/CRB clearance has a documented risk assessment in place, has a named supervisor (identified on the rota), is supernumerary to the care hour allocation and is not left unsupervised with service users or is allowed to
Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 29 16 YA34 17 YA34 26/10/05 undertake any personal care; until all information is in place and satisfactory clearances are received. 3) Documentary evidence, including 4 weeks staff rotas, must be forwarded to the CSCI Satellite Office – Halesowen for consideration, by 1700 hours on Wednesday 2 November 2005. 18 YA34 13(6) The registered person is 19(1)(4)(5) required to ensure that the 4 staff without a documented POVA first clearance are given leave and do not attend Agnes House or work any further shifts until a documented POVA clearance is received. Following the receipt of a satisfactory POVA clearance staff may only resume work in compliance with the conditions at requirement 2 (above). 13(6) The registered person is 19(1)(4)(5) required to consult the CSCI satellite office, Halesowen in any exceptional circumstances to allow the employment of persons on a POVA first basis, providing evidence of rigorous pre-employment checks, a documented risk assessment and copies of rotas with evidence of a named supervisor to ensure supervision at all times, until a satisfactory CRB clearance is received. 37(2) 39 The registered person must notify the CSCI office, Halesowen of any changes to the management arrangements for the home, including cover arrangements and contingency plans, without undue delay
DS0000004783.V260896.R01.S.doc 26/10/05 19 YA34 26/10/05 20 YA37 26/10/05 Agnes House Version 5.0 Page 30 21 YA41 37(2) The registered person must ensure that notifications are forwarded to the CSCI of any event affecting the well being of residents such as: 26/10/05 22 YA42 5 23(4) - Allegations of abuse - Suspension of staff members - Misconduct - Staffing shortages To include smoking 01/12/05 arrangements (SH): - In the resident’s individual contract - On the Home’s Fire Risk Assessment (Timescale of 31/03/04 and 30/06/05 Not Fully Met) To ensure that all high risk cooked food temperatures are consistently checked and documented (Timescale of 31/03/04 and 30/06/05 Not Fully Met) To ensure that there is an up to date Fire Risk Assessment for the home, available for inspection (Timescale of 31/07/05 Not Met) 23 YA42 18(1)(c) 24 YA42 17(2) Schedule 4(12) To provide ALL staff with updated mandatory training, including: basic first aid and infection control (Timescale of 31/07/05 Not Met) 1) To ensure accident records are fully and accurately completed 2) To undertake an up-to-date documented accident analysis, with a copy forwarded to the CSCI office, Halesowen 3) To undertake an up-to-date analysis of incidents / 01/01/06 01/12/05 Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 31 25 YA43 25 26 YA43 25 challenging behaviours for each resident, with copies forwarded to the CSCI office, Halesowen To develop a business and 01/12/05 financial plan, forwarding copies to the CSCI Area Office for consideration (Timescale of 31/03/04 and 30/06/05 Not Met) To send a copy of the last years 01/12/05 audited accounts for Agnes House to the CSCI satellite office, Halesowen (Timescale of 31/03/04 and 30/06/05 Not Met) 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 YA5 YA23 Good Practice Recommendations That the Organisation negotiates to obtain additional funding from the placing authority for additional day activities SH. That staff signatures are obtained to demonstrate that they have read and are familiar with the homes and the multi-agency procedures for protecting vulnerable adults Agnes House DS0000004783.V260896.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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