Inspection on 28/11/07 for Agnes House

This inspection was carried out on 28th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Agnes House 08/01/07

Agnes House 30/08/06

Agnes House 26/10/05

Agnes House 17/05/05

Agnes House 22/02/05

Agnes House 05/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Agnes House 77 - 79 Newbury Lane Oldbury West Midlands B69 1HE Lead Inspector Mrs Jean Edwards Key Unannounced Inspection 28th November 2007 08:00 Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 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 jasonlane@hotmail.co.uk Not known Alphonsus Homes 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) Karl Jason Lane Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 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 30th August 2006 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 40 people including the registered manager. Information regarding fees charged for living at the home is not included in the Statement of Purpose or Service User Guide. Interested parties are advised to contact the home direct if requiring this information. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the key unannounced inspection visit for 2007 - 8, undertaken by two inspectors from the Commission for Social Care Inspection (CSCI). This means the home has not been given prior notice of the inspection visit. The inspectors have spent one weekday at the home. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements includes: discussions with the registered manager and staff on duty during the visit, discussions with two residents, observations of residents without verbal communications and examination of a number of records. Other information was gathered before this inspection visit from the homes Annual Quality Assurance Assessment (AQAA), notification of incidents, accidents and events submitted to the CSCI. The CSCI sent out five service user surveys, relatives surveys, health care professional and staff surveys. An analysis of the 2 survey forms from service users, and responses from relatives, staff and health care professionals is contained throughout this report. There are currently five residents living at Agnes House, there are no vacancies and the home has not admitted any new residents since the key inspection in August 2006. Formal interviews with residents are not always appropriate therefore other methods such as informal chats, observations of body language, eye contact, gestures, interactions between staff and residents have been used. There has been a tour of the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission, where possible. Since the home was last inspected the CSCI has reviewed its procedures regarding issuing Requirements and Recommendations. As a result many of the Requirements previously identified have now been altered to Recommendations. What the service does well: Residents are encouraged to treat Agnes House as their own home and to be as independent as possible. Bedrooms are arranged and decorated according to each persons choice. Two residents who are able to communicate verbally say, they really like living at Agnes House and enjoy their independence. This home provides a secure and well adapted service for people with complex needs and behaviours, which offer considerable challenges for the service and staff. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 6 There are very comprehensive and detailed care plans and risk assessments in place for each person to guide staff to make sure good standards and safe care and support can be provided. People are generally able to attend daytime activities supported by the day care staff employed at Agnes House; one person attends college courses and is proud of his achievements. Activities continue to be geared to each person on an individual basis. All residents have been able go on one or more holidays this year, according to their wishes and abilities to cope. Residents are supported to maintain good contact with their families wherever this is possible. One person has been visiting their family during this inspection visit and another relative visiting the home has commented how much the family appreciate the support the home gives, especially providing staff as escorts to visit family members as far away as Manchester. Meals are provided individually for each person according to their likes and dislikes. The two of the residents at 77 Newbury Road do their own shopping and cooking, supported by staff. Residents are supported to maintain healthy lifestyles. Three residents have successfully managed to lose unwanted weight through healthy eating plans and exercise, which has benefits for their heath and wellbeing. There has been good communication and rapport between staff and residents during this inspection. Discussions with staff on duty demonstrate a dedicated and committed approach. The established core group of staff have answered questions in an open and honest manner and show they know about residents’ likes and dislikes and how to meet their needs. The organisation demonstrates a strong commitment to staff training, with its own training centre accredited with City & Guilds. The home is clean, tidy and homely and generally provides a safe environment. There is an on-going program of redecoration and replacement, which maintains a pleasant environment. We were shown full assistance during the visit and would like to thank everyone for the assistance and hospitality. What has improved since the last inspection? The registered manager and staff are continually trying to improve the ways in which each residents care is planned and improved records are being introduced. The homes complaints procedure has also been improved with the help of one of the residents living at 77 Newbury Road, and the procedure is now in easy read words with pictures to help everyone understand how to complain if they are not happy. The home has achieved the Five Alive gold level healthy eating award for the food provided for residents and is aiming to improve to the platinum level next year. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 7 The home has been redecorated, which makes the surroundings bright and airy and the heavily stained carpets in the communal areas at 79 Newbury Lane have been replaced, making the home look cleaner and more homely. The rear garden area at 77 Newbury Road is now better maintained and safer for residents to use. The home is now almost fully staffed, with just two vacant posts, and the manager has put in place a staff sickness absence policy and procedure, which means there are fewer staff absences and no staff are currently working excessive hours. This means that there are generally better arrangements to support residents with their daily life and leisure time activities. The registered manager has put in place an annual development plan, which sets targets for improvements to the service for the forthcoming year. He also makes sure that regular meetings are held with residents at 77 Newbury Road so that they can have their say about the running of their home. The home has distributed surveys to residents and relatives in March 2007 to find out their views about how well they feel their needs are being met. The manager has improved security for residents money held in temporary safekeeping, with generally better monitoring arrangements at the home. Improved measures have been put in place to control any potential risks of infections in the laundry area. What they could do better: At previous inspection visits there has been a requirement for all residents and their families or their representatives to be provided with a revised and detailed 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. The way the home manages residents medication require further small improvements, to safeguard the residents as much as possible. The registered manager must make sure that the multi-agency procedures to protect residents are followed diligently on every occasion of concern. Although the home has a copy of Sandwell MBC multi-agency procedure for the protection of vulnerable adults, and this has been used on two occasions in October 2006, the registered persons have failed to make referrals to the lead agency on two occasions in June and September 2007. The registered manager has conducted internal investigations on both occasions, which does not give assurances that vulnerable residents are properly protected. Furthermore at least one member of staff has responded, No I don’t know what to do if people raised concerns, to a question on the CSCI staff surveys. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 8 The registered manager must make arrangements for new bedroom flooring to be provided for the resident at 77 Newbury Road, in accordance with his preference and in response to his frequent and long standing requests for this to be done. The home continues to experience some difficulties in retaining and recruiting appropriate staff, though there has been some improvement recently. This remains a matter of concern and the registered person must monitor the situation and continue strategies to maintain staffing levels with sufficient numbers of trained, experienced, competent staff. Two residents have spoken about the shortage of drivers and responses to CSCI service users surveys are, Id like to go out more drives at night but not enough drivers on shift - but everything else is brilliant at Agnes House and I would like to be able to go for a drive every evening but I understand that I can only go at the moment when there is a driver on duty. All other aspects of my life and times at Agnes House is brilliant. Additional comments have been received from health care professional and relatives surveys, such as, very high staff turnover, staff continuity and could work better with professionals, some new staff are inexperienced, and the turnover of staff sometimes would throw this a little because they need to learn the skills of the needs of individuals from staff who do know and support them, until they know their needs. Furthermore the home must demonstrate a rigorous approach when recruiting staff, recording reasons for any gaps in any previous employment and checking work permits of staff from outside the UK. The registered persons must improve the quality assurance arrangements, and use formal surveys to seek the views of professional colleagues about the performance of the home and support for residents. Additionally the registered persons must make sure that unannounced monthly visits take place, with reports about the conduct of the home on a consistent basis. Some records at the home are good, however the registered manager must put in place additional arrangements to monitor all records, especially those relating to residents personal, health care and health and safety, and show what action has been taken where records are not satisfactory or missing. Concerns have been expressed to the CSCI and Local Authority about the condition and safety of the organisations cars used to transport residents on their day and leisure time activities. The Environmental Health Officer has strongly recommended that the cars are regularly serviced in accordance with manufacturers guidelines and the organisations own policies. The manager and some staff have also expressed concerns about the age and reliability of the cars, which they say frequently breakdown and need repairs. One car is no longer in use and the other two have very high mileages. The registered person must assess the risks attached to the use of these cars and put in place controls to minimise the known risks. As required at previous inspections the Registered Proprietor must make the business and financial plans available to the CSCI for consideration. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 10 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.V356772.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is adequate There is good evidence that all service users needs are reviewed and reassessed, with multi-disciplinary health care professionals. No progress has been made to provide a formal 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is evidence from discussions and examination of case files that residents needs are kept under review and are reassessed with other professionals involved in each persons care. For example residents have involvement from speech and language therapists, psychology teams, dieticians, community psychiatric nurses and social workers. The home is generally working to agreed strategies. The AQAA submitted by the home states what we could do better produce a pictorial statement of purpose and service user guide and produced a brochure for prospective service users, the registered manager says he has plans to Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 12 implement the statement of purpose and service user guide in formats appropriate to the residents abilities in the near future. The AQAA submitted by the home states what we do well up-to-date statement of terms and conditions for all service users are now in place which includes level of fees. At the inspection we established that the registered manager has devised written statements of terms and conditions, with a fee range inserted in order to try and meet the requirement outstanding for a considerable time. However this is not the formal contract of residency/terms and conditions between the organisation and the resident. 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 still not been met. There are no details of levels of individual fees or what is to be provided as a contractual arrangement. The Care Homes Regulations 2001, Regulation 5(2) requires care services to provide information relating to fees, which should be published in the service user guide. There is evidence from the AQAA, CSCI survey responses, discussions and documents provided at the inspection visit that the registered manager has recruited increased numbers of staff, though not all have the experience, training, and competence to meet the complex and diverse needs of the five residents accommodated. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good There is a clear and consistent care planning system in place providing staff with the information they need to meet each person’s assessed needs. The person centred planning approach means that residents have as much control as possible over their lifestyle and care. Risk assessments are in place to cover all aspects of personal and social, and health care; this improves protection for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents files seen contain information that is clear and has generally been completed satisfactorily by staff. Residents files have not been examined in their entirety, as there have been no new residents since the last inspection. We looked at ABC (antecedent, behaviour and consequence) charts for three residents. Two peoples ABC charts have been filled in comprehensively, there are no gaps and staff had written clear explanations of interventions they had used and the behaviours that had been displayed. The registered manager Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 14 also completes a monthly behavioural analysis for each resident; this helps with the evaluations of care planning and has been developed in different ways to meet different people’s needs. All interventions are recorded on a scale of 1, 2 3, with level 3 intervention requiring two people holding the persons arms and a third holding their head to prevent injury to themselves. The third residents records we examined had 17 ABCs recorded in a recent 4week period. The psychologist from Heath Lane Hospital is closely involved in this persons care and support. The records to be used are detailed showing the use of agreed MAPPA strategies. Some records are very well completed whilst others have only very basic information recorded. One ABC chart does not record the build up to the behaviour and the only detail of the agreed strategy used, is of the person being warned to stop or they would be restrained, the chart shows they were restrained but no details of the technique used or the duration. This persons file has a number of body maps, which show unexplained injuries. There is body map 17/9/07 showing cuts to both wrists and an accident record dated 17/9/07, which only gives details of banging on wicker, these do not correspond to other records on file. There are 4 other body maps between 20/10/07 and 11/11/07 showing marks / injuries, but no accident records, although there are 9 other recorded accidents involving this resident in November 2007. A suggestion has been made that they may have occurred in altercations / contacts with other residents at 79 Newbury Road. We have looked at a sample of daily records and spoken to the registered manager and staff, which confirm that any of the three residents living at this house may lash out at one of the others occasionally. These incidents must be fully recorded and referred as necessary through the safeguarding procedures. Communication plans are good and give staff clear guidance on how to respond to each individual resident. We have seen a very good example of adapted Makaton signs in a booklet form for one person. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good There are social activities and stimulation with improved staffing arrangements and as a result each person is now generally able to participate in appropriate activities to follow their own hobbies and interests and develop their personal potential. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents who have verbal communication skills have told us that they enjoy going out, and they have an active life. Generally they feel that staff support them to do this but there are occasions when they have been unable to leave the home because there have not been enough drivers to take them. One resident also told us that on occasions when she has used the car the seat has been wet, this is as a result of other residents having been incontinent on the seat before she got in. We have observed continence products of the seat of the Seat car. The concerns about the condition of the organisations vehicles are highlighted in more detail in the Management section of this report. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 16 Another resident has told us about his college course and how much he is enjoying it. He has recently passed his food hygiene training and has been very helpful in producing the pictorial complaint document for the home. The residents are encouraged to go to the cinema, swimming and the local health club. There is a pub opposite the home and two of the more able residents say they like to go there for a drink and meal. Some of the residents bedrooms have seen and it is pleasing to note that they have been personalised to individual tastes. One person has a play station and a computer in his room and enjoys using them. Another resident has a personal computer, given as a present from parents and is able to use homes Internet to book tickets to go to concerts, such as Meat Loaf and Status Quo. Residents at 77 Newbury Road have also told us that they have been on holiday recently to the Lake District. We are told that staff strive to take people on holiday at least twice a year. The day care staff are responsible for the day-to-day activity of residents, and during the inspection people have been to Merry Hill shopping, to the Malvern Hills for a walk and one person on a visits to their family home. A person who wished to remain anonymous raised concerns with the CSCI about the quality of food at the home. We have seen evidence that meals are planned with residents wherever possible. Additionally the home has been independently awarded the gold award for five for life from Sandwell Primary Care Trust. The home has received advice about providing pictorial menus for the residents at 79 Newbury Road and plans to strive to reach the platinum award next year. We have seen menus, which are healthy and provide a lot of variety. Some residents are given a daily budget and buy their own meals for preparation later that day. Spaghetti Bolognese is on the menu on the day of inspection, we have seen one person doing the cooking and another washing up supported by staff. We are told, “thats the deal we have”. There is plenty of food in the cupboards, including tins of peas and carrots but the registered manager and staff have said that they like to buy food fresh and make it on the premises. Food records are satisfactory, with staff recording food temperatures before serving residents. One resident is a non-practising Muslim and we are told that his family are happy for him to have Western food, and his mother brings cultural food for him to eat twice a week. However this persons food charts show records of sausages and bacon as part of food eaten. Staff are aware of the final rituals to be observed to respect this persons and his familys cultural needs. We are told that residents are given money to pay for their meals when they are away from the home and for those who budget their own meals they are given £10 a day each to spend on their meals. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 17 There are a small number of issues relating to food safety. The fridge in 79 Newbury Road needs to be repaired or replaced because the seal is no longer working as it should and a drawer front is missing in the upright freezer at 77 Newbury Road. At this house the fridge thermometer is reading 8C and has been a number of days, this is in excess of the temperature recommended in a recent Environmental Health Report. We noted a container of mayonnaise dated 13/10/07, which should have been used within 4 weeks of opening and a bottle of brown sauce, which was opened but undated, staff discarded both items. We also noted that an opened pack of cereal in the wall cupboard, which has not been resealed or stored in a pest proof container. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good The health needs of residents are generally well met with good evidence of multi disciplinary working taking place on a regular basis. There systems for the administration of medication generally offer assurances that residents’ medication needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a key worker and link worker, generally working in teams, which enhances support for all aspects of care and development. Each person is encouraged to be as independent as possible. Records, observations and discussions with two residents and staff describe how residents’ privacy and dignity are respected and how their independence is maintained. The two residents at 77 Newbury Road take overall responsibility for their own personal hygiene, generally only requiring verbal prompts. The other three residents are supported to undertake small personal tasks according to their capabilities and are given sensitive support to maintain good levels of personal hygiene and good grooming. There are detailed records in place on individual plans identifying the level of support residents require with personal care. However we are concerned to read an entry dated 28/10/07 in the homes Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 19 communication handover book X 6:40 am soaking wet bed soaking ... so morning staff had to do X PHR (we are told this is Personal Hygiene Routine) in the end because nobody else could be bothered to do X. We discussed this entry with the registered manager, who states he was not aware of it. We have requested that the manager investigates this incident and reports the outcome to the CSCI. There are also a small number comments from CSCI relatives surveys indicating that more care could be taken with the personal appearance and care with laundering residents clothing. The manager has told us that he is aware of some concerns and has addressed them with the staff team. Each person has detailed health care records, which demonstrate that the majority of health care checks are up to date. All residents receive annual health-care checks. However the manager has expressed his concern that one resident has not had blood tests relating to anti-convulsion medication for 4 years because of the difficulties presented to health professions relating to this persons very challenging behaviours, in addition the allocated CPN has changed jobs, therefore there is currently no allocated worker. We have advised the manager to document his concerns to the relevant healthcare and social care professionals. Weight records show that with support and with a healthy diet 3 residents have managed to reduce their weight. The residents use the services of health care professionals such as the NHS dentists, who make visits to the home, often making visits until the resident is comfortable with them and allows examination or treatment to take place. This is less disruptive for residents. However a comment from a health professional survey states, not always reliable about supporting my client to attend appointments on time The registered manager tells us that this comment may refer to a resident who goes out independently and does not always choose to return to attend appointments. We advise that strategies and good communication systems be introduced to make sure as far as possible residents health needs are met and health care professionals are kept informed, where this is not working. Another comment from health care professional surveys about what the home could do better states, staff continuity and could work better with professionals. The homes medication system is generally good; there is a medication procedure on the medication cupboard in each house. We have randomly audited samples of medication, which are accurate. There are good PRN (give as required) protocols in place for residents and staff. This gives clear indication of when staff should consider the use of PRN medication. The home has no residents with controlled medication at this time. However we noted that external preparations are still being stored with oral medication. Bactroban cream for a resident is being stored on the same shelf as the oral medication. This needs to be moved to avoid errors. There is a prescription for a resident requiring aqueous cream stating, “as required” but not the frequency of administration. This is only being put on once a day, and Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 20 staff confirm that this is correct but they need to make sure that the MAR sheet reflects this. There are no medications that require cold storage at present. Staff have received training and those who administer medicine all have certificates of achievement in their training file. The registered manager tells us that staff are only awarded a certificate after completion of theory and practical observation test. Once the tutor is satisfied the worker is competent they are given their certificate. Records show that two care staff both sign the MAR sheet at present but this does not need to continue. Only the person who administers the medication should sign the MAR chart. The other member of staff witnessing the process further safeguards residents but there is no need to sign MAR sheet, which could cause confusion as to who actually administers the medication. The homes medication policy needs to reflect the protocol for medication taken outside the home. There are 2 support workers are also drivers and administer medication to residents, during their daytime leisure activities. There is evidence that they have medication training and their names are on the specimen signature list. There is information on the list to show support workers / drivers not authorised to administer medication, though this list needs to be updated as it includes 2 staff who no longer work at the home. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate The home has a comprehensive complaints system with some evidence that staff understand the need to listen and to act upon areas of concern. The complaints procedure is now provided in alternative pictorial formats needed for residents without verbal communication skills. Policies, procedures, guidance and staff training have not been fully implemented in order to provide residents with safeguards from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive complaints procedure, and there is now a pictorial format for those residents without verbal or written communication skills. The AQAA submitted by the home indicates that there have been 2 complaints, both resolved within 28 days. The details of the complaints are recorded in the homes complaints log. One complaint dated 29/10/07 from a relative raises concerns about a lack of care with clothing laundered at the home and with the lack of care and attention to the residents personal appearance. The registered manager has recorded that he has spoken with the complainant regarding the outcome but there is no record of a formal response. The registered manager must give written responses to formal written complaints, eliciting a response as to whether they are satisfied. Additionally it would demonstrate good practice to follow this process for all complaints. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 22 The AQAA submitted by the home states all complaints are dealt with as per organisational policy, we have a whistle blowing policy in place, all staff have read and signed to say they have read and understood all company policies, staff have had training and LDAF training which also covers abuse. However the CSCI staff survey contains a comment, No I don’t know what to do if people raised concerns. The AQAA submitted by the home indicates that there have been no allegations of abuse however the service record shows that there was an incident 10/10/06, involving a member of staff towards a resident, reported to police, no action taken, but investigated by the home and the member of staff dismissed. The Ambulance Service referred an incident regarding a medication error on 16/10/06 to the PCT and Local Authority, which was investigated by the organisation, with remedial actions for improvements to be implemented. Furthermore records at the home show that there have been two incidents, which the registered manager acknowledges have not been reported to all relevant agencies, and in particular Sandwell Social Services, which is the lead agency for Safeguarding Adults. There was a theft of a considerable amount of a residents personal allowance held in the homes safe between 12th and 13th June 2007. This was reported to the police but not investigated by them. The registered manager tells us that this is because the homes safekeeping procedure had been breached, and too many staff had been allowed access to the safe. The actions recorded at the home relate only to putting in place remedial measures. However there is no clear evidence of what action has been taken to investigate how this had happened, with staff responsible identified. The second incident between the 17 - 21 September relates to incidents, which are alleged to have taken place during a holiday with two residents in Fleetwood, Lancashire. The incidents were reported to the registered manager by two staff making a formal complaint, in effect whistle blowing. The registered manager suspended a member of staff, conducted an internal investigation and subsequently dismissed a member of care staff for verbal abuse and issued a written warning to the senior residential care officer, for 6 months, for failing to fulfil duties and responsibilities. The member of care staff appealed against the outcome and was reinstated by senior managers from the organisation and later resigned. There is a record of a regulation 37 notification at the home dated 11 October 2007, which does not appear on the CSCI database as being received. In addition the CSCI has recently received information from a caller wishing to remain anonymous. The concerns are about the safety and reliability of the organisations cars used to transport residents, putting residents and staff in danger, the poor quality of the food provided and some incidental comments about an alleged incident some months ago, which has potential health risks for a resident, which do not appear to have been understood by the caller. The Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 23 information has been referred to Sandwell Social Services, as the lead agency, in accordance with the multi-agency safeguarding procedures. We have made the registered manager aware of the call but not full and specific details. He is aware that the Environmental Services have been contacted to look into the allegations about the vehicles, as the visit had taken place and details of findings are recorded in the Management Section of this report. The allegations about food have been looked into as part of this inspection and are not upheld. The records of the residents have been examined as part of this inspection and no written evidence relating to incidental comments about an alleged incident has been found. We have asked the registered manager whether any untoward incidents have been brought to his attention apart from those already documented; he says there are none. Further investigations are continuing involving a multi-disciplinary approach, which will also involve the organisation as deemed appropriate. We have checked all residents monies held at the home, which all balance, and there are no omissions. The home obtains receipts for all transactions; there are separate records for residents personal money, day care and petty cash. No residents monies are pooled and the home has good systems in place to manage individual personal allowances. The home has improved systems for safeguarding temporary safe keeping of residents money. We have found an entry in one person’s ledger to say that they had purchased a new phone for the home after having broken the other one during a behavioural outburst. This has been discussed with the manager who confirmed that this had happened. He is required to reimbursing the resident and ensures that any such arrangement is discussed and agreed in a multidisciplinary arena, prior to implementation. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26,27, 29,30 Quality in this outcome area is good 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Agnes House is comprised of two bungalows; 77 Newbury Road is a twobedroom bungalow and 79 Newbury Road is a three-bedroom bungalow. A tour of the premise has undertaken and all of the residents rooms with the exception of one have seen. They have been personalised as much as they can be, and most residents have televisions, DVD players and one person has a computer in their rooms. The home has taken steps to protect residents by placing their televisions on high fixing-wall brackets, which reduces the risk to residents. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 25 The home has one main bathing facility in each bungalow, one has been decorated to the choice of the two residents living there but the other appears utilitarian, is stacked with aprons and gloves and does not appear inviting or relaxing. One of the residents has a problem with continence and frequently urinates on the floor and furniture, this persons bedroom has a malodour, and though the registered manager states that the flooring has been replaced with laminate, the malodour suggests that the urine has seeped under the flooring into the floorboards and into the skirting boards. The fridge in the kitchen at 79 Newbury Road has a broken seal, and although the fridge retains a cool temperature this should be rectified and be either repaired or replaced. There are improvements to the communal areas of the home, with new carpets at 79 Newbury Road. Both bungalows look relaxing, and one of the residents has provided the artwork for at 77 Newbury Road. The garden areas have been improved, and 77 Newbury Road now has a lawned area instead of the bark chipping, which residents appreciate, especially as they say that dirt is no longer trod into their bungalow. However the security light to the rear of 77 Newbury Road needs to be repaired so that residents and staff can see where they are going when they get into the rear garden, which is a link-way between the two bungalows. The rear door from 77 Newbury Road does not close correctly into its rebate and when this is replaced the door needs to have a suitable glazed unit to give natural light into the quiet room, which currently has no natural light. The garden at 79 Newbury Road has been decorated and painted in bright colours, incorporating all of the residents names. There is also a shed that has some sensory equipment in it for residents use, however the manager states that it is not fully equipped as yet and the home is waiting for further equipment. We noted that a second shed in the vicinity had been left unlocked and is being used to store cleaning products such as urine neutraliser. This poses a risk to residents who are speedily put items into their mouths. This has been discussed with the registered manager during the inspection visit and he has agreed to take remedial action. One resident has told us that he has repeatedly asked for new flooring in his bedroom, this is confirmed by the registered manager and staff; and substantiated in notes of residents meetings and reports from the home, however there is no action to meet this request. The laundry is small and residents are encouraged to help with cleaning their own clothes wherever possible. We noted that clothing has been sorted into separate baskets, waiting for washing. There are gloves and aprons available for both staff and residents to use to help reduce the risk of cross infection. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is adequate There continues to be a relatively high staff turnover, with high numbers of new staff, this has the potential for residents not to receive consistent care. Recruitment and selection processes do not always assure sufficient safeguards and continuity for the vulnerable people living at the home. The outcomes of the strong commitment to training continue to be diluted due to the high staff turnover. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA submitted by the home states, what we do well, there is always the staffing levels on shift, all required documents are in staff files; staff have the competence and qualities to assist the service users and support behaviour needs; 90 of staff are MAPPA trained; over 50 of staff hold or are working towards a NVQ / LDAF award: our aim is to achieve monthly staff supervision and appraisal as required by the NMS; all staff have a CRB and POVA check on file: staff turn over is low: the home operates a very thorough recruitment process in line with current legislation; ...... we have a robust handover system in place ; and the AQAA section, our evidence to show that we do it well, Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 27 states documentation in the home. The section of the AQAA titled what we could do better has no entries. During the inspection visit we have requested copies of staffing rotas, quarterly staffing returns submitted to the organisation and staff training records. From assessment of the information, and discussions with the registered manager and staff on duty it is evident that there continues to be a relatively high staff turnover, though the registered managers assertion is that the staff situation is more stable. The number of staff employed has certainly improved and there are approximately 40 staff employed, though the numbers in various records do not entirely correspond. For example the staff rota shows 35 names and two vacancies and a staffing list supplied to the CSCI has 39 names. The manager told us that some staff names were omitted from the staff rota because they were currently not working in the home. According to the homes records 13 staff have left the homes employ in the past 12 months for a variety of reasons, including 2 transfers to other homes in the organisation, 2 staff dismissed and 2 people who did not complete a satisfactory probation period. Currently the staff rota shows that there are two for weekend posts. The registered manager states he conducts exit interviews wherever possible and believes the rate of pay allowed by the organisation is a contributory factor, especially for the care of people with complex needs and behaviours, which are very challenging. Staffing levels are maintained by existing staff, however there is no evidence that people are continuing to work excessively long hours. Records submitted by the home show that 14 new staff have been employed since November 2006 and a total of 21 new staff since the last inspection on 30 August 2006. This continual progression of new faces does not create the stability and continuity the residents with Autistic conditions need. One resident who can communicate has told us that he has had 16 ABCs in the past month, he says its because he feels angry and says its lots of new faces, although the manager cites family relationships as a reason. The staff providing support for this person on the day of this inspection who have been in post since March and May 2007 state that the introduction of new staff does have a bearing on residents behaviours. As indicated at the previous inspection visit in August 2006, there is evidence that some staff come to Agnes House receive the training and then leave for better paid prospects in similar organisations. The organisation should take heed of the impact of less than favourable terms and conditions of employment; on the continuity of care for residents, staff morale and recruitment and training costs to the service. A comment from the CSCI staff survey states, “sometimes when staff ring in sick of have leave there are not enough staff to offer full support to the service users.” There are also comments from health professionals about the high staff turnover being detrimental to the continuity of the care and support of residents. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 28 Some responses to the CSCI relatives survey about sufficiently experienced and skilled staff to meet residents needs are, some new staff are inexperienced, and the turnover of staff sometimes would throw this a little because they need to learn the skills of the needs of individuals from staff who do know and support them, until they know their needs The home has a good system of handover of verbal information at each shift change, supported by comprehensive printed handover sheets, and whilst some are well completed, unfortunately some are incomplete or entirely blank for some days, which is not always followed up by the people in charge of the home. Examples at 79 Newbury Road are on 5/5/07 - nothing entered; 26/10/07 - incomplete, and 28/10/07 - incomplete. We have examined the personnel records of 6 staff and whilst the organisation has robust recruitment procedures in place there are some areas in need of improvement to demonstrate compliance with legislation and provide satisfactory safeguards for the vulnerable people living at Agnes House. One staff file has no written explanation for a gap in employment history, and another file does not have a reference from the last employer in a care capacity. One person has an updated contract / terms and conditions but has no mention of duties as a driver, though the driving documentation is held on another separate file. The files of two staff from outside the UK do not have evidence of work permits or conditions for their employment, though their passports show that they are in the UK as students. The registered manager has submitted Home Office documentation following the inspection visit, which indicates that must not work more than 20 hours per week in term-time, and that your stay in the United Kingdom as a student will give you no claim to remain in the United Kingdom when your studies are completed. From the small sample of staff files there is evidence to show that the registered manager has employed one overseas student, contracted to work 22 hours per week on a permanent contract as a night support worker. However because the monthly staff rota does not show full names, designations and the total of actual hours each person has worked it is not possible to determine whether Home Office rules are being breached or compiled with. We have not been able to verify through records, the claim that the home is meeting the target of 50 of staff with an NVQ 2 / LDAF equivalent award. Although the organisation provides a strong commitment to staff training and development and there is evidence from discussions that staff value training and development opportunities, the effect of the continual staff turnover continues to diminish the positive outcomes of training and supervision. The supervision records we have examined are very detailed and the supervisor it to be commended. A comment from the CSCI staff survey states, “ I found the induction very useful as I have never worked in learning disabilities or challenging behaviour before. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 29 Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 30 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40,41, 42,43 Quality in this outcome area is adequate The manager is generally supported well by the senior staff in providing leadership throughout the home. The staff group demonstrate an improved awareness of their roles and responsibilities. Monitoring arrangements are not always ensuring poor practice is dealt with and this compromises safeguards for the health, safety and well being of persons using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager, Jason Lane, has been in the post since February 2005. He is registered as a candidate undertaking the Registered Managers Award (RMA), he tells us he has changed assessors and plans to complete the award in the next few months. He has recently achieved the A1 NVQ Assessors Award through the organisations accredited training centre. The staff on duty, staff surveys, two residents and a relative spoken to during this inspection visit say that he is approachable and supportive. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 31 The home does not have an externally accredited quality assurance system, however the organisation has an internal system, which includes twice yearly audits conducted by managers from other homes within the organisation. The audit reports are made available to the home and registered provider. The registered manager the home has implemented any service user, relatives questionnaires in May for the current year. Stakeholders questionnaires have not yet been circulated. The home now has an annual development plan, which identifies targets for improvements in this 12 months. Discussions have taken place relating to the new Regulation requiring the home to submit an annual AQAA on request by the CSCI and it is recommended that the registered manager proactively use this as an additional tool. In addition the evidence to support statements made in the AQAA need to be more detailed and accurate, as the evidence will be tested and verified as accurate or not during inspections. The home has copies of a comprehensive range of organisational policies, procedures and guidance, however the relevant ones have not yet been produced in alternative formats, such as symbols or pictures, suitable to residents capabilities, at the previous inspection it was recommended that all policies, procedures and good practice guidance must be regularly reviewed, updated and signed by the registered manager. There are gaps in review dates in significant policies on the AQAA submitted by the registered manager, notably codes of conduct, COSHH, contact with family, friends, disposal of clinical waste, emergency admission & detention Mental Health Act 1983, Food safety & nutrition, individual planning & review, missing service users, moving & handling, and referral & admission. Though the general improvement in the standard of record keeping across a number of areas, there are a number of intermittent and significant failures to keep full and accurate records. Examples are inadequate ABC charts for one resident, missing accident records for one resident, incomplete handover sheets and failures to make timely notifications to the CSCI in compliance with Regulation 37 about the suspension and dismissal and disciplinary action of 2 care staff and failure to make referrals to the Local Authority relating to theft of a residents money and allegations of abusive behaviour. An anonymous concern has been raised with the CSCI relating to the roadworthiness of the vehicles used to transport the residents on their leisure activities. The concern has been passed to the Local Authority Environmental Services / Health & Safety for their view. An Environmental Health Officer has visited the home and written to the registered persons. He notes that two vehicles are in use and both have current MOTs certificates, weekly checks are carried out on the vehicles by employees and documented. It appears that no routine servicing is being carried out in accordance with vehicle manufacturer Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 32 guidelines. He points out there is no legal requirement to service road vehicles, but it is an offence under section 40A of the Road traffic act 1988 to use or cause or permit another to use the motor vehicle on a road when the condition of the motor vehicle is such that the use of the motor vehicle involves a danger of injury to any person He goes on to say as both vehicles have had a recent MOT, there is no suggestion that they are currently in a dangerous condition. He states that the companys transport policy and guidelines both refer to servicing of vehicles as being required and has advised the organisation that the service of vehicles in line with their policies and further advised that failure to do so might be considered a failure to reduce as far as is reasonably practicable to Mr employees and others who might be affected, which is an offence under the Health and Safety at Work Act 1974. At the time of this inspection there is evidence that both vehicles have now been serviced and remedial work undertaken. However we are told that the homes third car, a Ford Escort, has been taken out of service and the home currently has an M reg Seat, which has 166,419 miles on the clock. This vehicle has a broken door handle on the front passenger side making an exit from the car difficult and it also has a broken sill below the passenger seat, which poses a potential hazard. The support worker/driver who uses this car takes a pride in trying to keep it looking clean and tidy, however the staff state that both cars are unreliable and regularly break down, needing repairs. The second car used is an L Reg Rover, which has 92,132 miles on the clock. The staff say that there is a safety problem, particularly when one resident is able to wind down the window and deactivate the child lock whilst car is in motion. This issue needs to be included as part of the risk assessment. This car is not maintained in the same clean and tidy condition as the Seat and incontinence pads (used as incontinence aids) are in view on the rear seat; this does not maintain the dignity of residents using this vehicle. The weekly checklists show that external checks are completed but generally internal checks of the vehicles are not completed and there are no entries on the defect reporting sheet. The registered manager tells us that staff have reported their concerns about the age and unreliability of the vehicles, he agrees with staff that they may present risks and has shown us documentation from AA callouts when the vehicles have broken down. An example is 27/1/06 vehicle found resting against a lamppost, referring to the Rover. He states that he has written to the registered provider advising him of the concerns. We have advised the registered manager that he must put in place risk assessments for the use of the vehicles until such time as the vehicles are replaced and that furthermore he has a responsibility to make sure that all activities are conducted safely and that he must take appropriate action where he feels safety is being compromised. Accident records have been examined and according to the homes monthly analysis there have been 18 recorded accidents involving residents and 73 recorded accidents involving staff and 39 records of incidents of violence Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 33 towards members of staff since January 2007 to 31 October 2007. However we are aware that from the examination of one residents case file, body maps show unexplained injuries, which are not recorded in accident records and there are references to unexplained injuries, which we are told may be just marks on two other residents indicated in the handover sheet on 30/10/07. Additionally another resident tells us he has injured his hand, which has had medical attention but there is no accident record for this injury. Random samples of fire safety, health and safety, maintenance and training records have been assessed. Health and safety checks are generally in place, the Landlords gas safety certificate is dated 24/04/07. Hot water temperatures are recorded but not always reaching required temperatures. During the checks in October 2007 staff have recorded that at 79 Newbury Road, bedroom 2 only had a hot water temperature of 18.6C and at 77 Newbury Road the hot water temperature at the bath outlet only reached 36.0C. This has been brought to the registered manager’s attention and he states that a new recording book is in place for recording of hot water temperatures and that there had been no problems throughout November 2007. He is requested to record what actions he will take if the hot water temperatures fall below recommended levels again. The five-yearly fixed wiring service, previously checked in 2000, has recently been undertaken, with remedial work completed, we have requested that a copy of the service certificate be forwarded to the CSCI office, Birmingham. There are gaps in the staff training, particularly first aid only 10 out of the current staff group of 37 have completed this training. In addition 12 staff need to complete moving and handling training. The registered manager states that the organisation has its own training centre, which arranges all the training for staff. The training matrix shows that all staff have received infection control training. Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 34 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 2 32 1 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 N/A 12 3 13 4 14 4 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 2 2 2 2 Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 35 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5(1)(b)(c) 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 and 01/11/06 Not Met) It is the home’s responsibility to notify the CSCI when this requirement is met. 2. YA5 5(1) To ensure individual fee levels and details of what is included is made available to residents / their representatives (Timescale of 31/03/04 and 01/11/06 Not Met) It is the home’s responsibility to notify the CSCI when this requirement is met. 3. YA9 13(5) The registered manager must document monitoring and evaluation for all records of ABC charts and reports of use of restraint of all residents to DS0000004783.V356772.R01.S.doc Timescale for action 01/02/08 01/02/08 01/01/08 Agnes House Version 5.2 Page 36 identify discrepancies It is the home’s responsibility to notify the CSCI when this requirement is met. The registered manager must 01/01/08 ensure that all unexplained injuries on residents body maps or referred to in written records are investigated with supporting documentation It is the home’s responsibility to notify the CSCI when this requirement is met. 5. YA20 13(2) 1) To review and expand the homes medication policy and procedures to include all aspects of medication administration at Agnes House (Timescale of 01/11/06 Not Fully Met) 2) To ensure that internal and external medications are stored separately (Timescale of 01/11/06 Not Fully Met) It is the home’s responsibility to notify the CSCI when this requirement is met. 6. YA20 13(2) 1) To clarify any items prescribed “as required” including creams with the prescriber and / or the pharmacist. 2) To ensure that only one member of staff signs the MAR sheet to indicate administration has taken place. It is the home’s Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 37 4. YA19 12(1) 13(4) 01/02/08 01/02/08 responsibility to notify the CSCI when this requirement is met. 7. YA23 13(6) 1) The registered manager must forward full details of the two incidents, in June and September 2007, which have been investigated internally by the organisation, to the lead agency to demonstrate compliance with the multiagency safeguarding procedures 2) The registered manager must diligently follow the multiagency safeguarding procedure in future, ensuring referrals of allegations of potential abuse are made without delay It is the home’s responsibility to notify the CSCI when this requirement is met. 8. YA23 13(6) 1) The registered manager must cease to require the residents at 77 Newbury Road to pay for items broken as a result of their behaviours unless this has been agreed within the multidisciplinary team and forms part of the residents contract of residence 2) The registered manager must, in the interim, reimburse the resident charged for a broken telephone It is the home’s responsibility to notify the CSCI when this requirement is met. 9. YA39 24 To ensure that written reports of Regulation 26 visits by the DS0000004783.V356772.R01.S.doc 10/12/07 01/01/08 01/02/08 Agnes House Version 5.2 Page 38 organisations nominated representative are copied consistently to the home and the CSCI on a monthly basis (Timescale of 01/10/06 Not Fully Met) It is the home’s responsibility to notify the CSCI when this requirement is met. 10. 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: - Suspension of staff members - Misconduct / disciplinary action (Timescale of 26/10/06 Not Met and 01/10/06) It is the home’s responsibility to notify the CSCI when this requirement is met. 11. YA41 13(6) 17(2) To implement a secure system for key-holding (code) to safeguard service users valuables held in safe-keeping (Timescale of 01/11/06 Not Fully Met) It is the home’s responsibility to notify the CSCI when this requirement is met To include smoking arrangements (SH): - In the resident’s individual contract (Timescale of 01/11/06 Not Met) It is the home’s Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 39 01/01/08 01/01/08 12. YA42 23(4) 01/02/08 responsibility to notify the CSCI when this requirement is met. 13. YA42 18(1)(c) To provide ALL staff with updated mandatory training, including: basic first aid, food hygiene and moving and handling (Timescale of 31/07/05 and 01/11/06 Not Fully Met) It is the home’s responsibility to notify the CSCI when this requirement is met. 14 YA42 13(4) 17(2) The registered manager must ensure that there are systems in place for all accidents involving residents to be fully and accurately recorded and evaluated It is the home’s responsibility to notify the CSCI when this requirement is met. 15 YA42 13(4) The registered manager must devise and implement risk assessments for the use of the organisations ageing vehicles, including documented strategies and contingencies to be activated when the vehicles either breakdown or are in need of repair, until such time as they are replaced with more reliable models It is the home’s responsibility to notify the CSCI when this requirement is met. 16 YA42 13(4) The registered manager must ensure that a shed at 79 DS0000004783.V356772.R01.S.doc 01/01/08 01/01/08 01/01/08 01/12/07 Agnes House Version 5.2 Page 40 Newbury Road, used to store cleaning products such as urine neutraliser, must be suitably secured at all times. It is the home’s responsibility to notify the CSCI when this requirement is 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 YA1 YA1 Good Practice Recommendations That the range of fees and any additional charges is clearly documented in the service user guide That the plans identified the AQAA to provide the statement of purpose and service user guide in formats appropriate to the residents abilities are implemented That the contract / terms and conditions takes account of the publication from the Office of Fair Trading relating to Contracts and terms & conditions in Care Homes That written consent be obtained from the relatives / supporters of the resident, who is a non-practising Muslim, to demonstrate that consumption of pork products as part of the western diet is acceptable and this should then form part of his dietary care plan. 1) That the specimen signature list for staff administering medication be maintained up to date 2) That the signatures of all staff involved in the administration of medication be obtained to demonstrate their awareness and compliance of revised medication policy and procedures 6. YA22 That the registered manager formally responds to the written complaint from a relative (29/10/07) about laundry DS0000004783.V356772.R01.S.doc Version 5.2 Page 41 3. YA5 4. YA17 5. YA20 Agnes House and the residents appearance, establishing that the complainant is satisfied with the outcome 7. YA24 1) That the defective fridge seal at 77 Newbury Road be repaired or replaced 2) That the broken drawer front in the freezer at 77 Newbury Road be replaced and ensure fridges and freezers are regularly maintained 3) That the exterior light to rear of 77 Newbury Road be repaired or replaced 4) That the frequent requests of the resident at 77 Newbury Road for the bedroom flooring to be replaced are actioned as a priority 5) That the rear door from the quiet room to the rear garden at 77 Newbury Road is replaced and any new door should provide natural light for the room (i.e. have a suitable window) 5) That further action be taken to eradicate the malodour in the identified bedroom at 79 Newbury Road, 8. YA34 1) To ensure that there is a full employment history on all applications forms, with a documented explanation for any gaps in employment (Not Fully Met) 2) That there is an accurate, up to date job description(s) on individual personnel files, reflecting the duties undertaken, including driving duties, where this is applicable 3) That there is a satisfactory written reference, on each personnel file, from the most recent employer (related to caring) wherever possible or documented reasons why not possible 4) That full documentation is obtained for staff from outside the UK, including work permits or any special conditions attached to their right to undertake paid employment and this is available on their personnel file 5) That staff rotas include full names, designations and total of weekly / monthly hours worked 9. YA34 That the registered persons devise a recruitment and DS0000004783.V356772.R01.S.doc Version 5.2 Page 42 Agnes House retention strategy to reduce the continual turnover of staff, improve the stability of the staff group and the continuity of care for residents 10. YA35 1) That all individual staff training profiles and plans are maintained to be up to date and provide evidence all staff have attended a minimum 5 days (pro rata) paid training each year 2) That the registered persons devise and implement a strategy to ensure that a minimum of 50 of care staff have an NVQ level 2 care award or LDAF award or equivalent within 6 months 11 YA37 That the registered manager has with regular documented supervision sessions from the organisation for support and professional development That the homes Annual Quality Assurance Assessments (AQAA) submitted to the CSCI should contain accurate, verified information and fuller details of the supporting evidence of what the home does well and the improvements made That stakeholder surveys are implemented, with results collated, published and acted upon where necessary 1) That all records are fully and accurately completed, for example daily handover sheets, which also contain records of medication keys at shift handovers 2) That the registered manager implements documented monitoring arrangements to show remedial actions taken and an indication of outcomes, where concerns are recorded on the daily handover sheets 15 YA42 1) That all vehicles owned by the organisation and used to transport residents have regular, routine, documented servicing and maintenance in compliance with the organisations policies 2) That the vehicles weekly documented checks are consistently and fully completed (interior and exterior) with records of any faults and remedial action recorded 3) That incontinence pads are not left on show on the rear seats and that seats are maintained in a clean, dry condition for residents comfort and safety Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 43 12 YA39 13 14 YA39 YA41 16 YA42 That the organisation gives serious consideration to replacements for the vehicles, which are ageing and have very high mileages, used to transport residents That the registered manager ensures that the hot water temperature at all outlets is maintained between 38C and 43C (41C for showers) and records remedial action he has taken should the hot water temperatures fall below recommended levels again. That the registered persons develop a business and financial plan, forwarding copies to the CSCI for consideration That the registered provider makes available a copy of the last years audited accounts for Agnes House to the CSCI 17 YA42 18 YA43 19 YA43 Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 44 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Agnes House DS0000004783.V356772.R01.S.doc Version 5.2 Page 45 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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