Inspection on 04/04/05 for Agnes House

This inspection was carried out on 4th April 2005.

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

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

Other inspections for this house

Agnes House 15/08/07

Agnes House 02/05/06

Agnes House 13/09/05

Agnes House 10/11/04

Agnes House 07/06/04

Agnes House 05/02/04

Similar services:

Applegarth

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Agnes House Wyggestons House Hinckley Road Leicester LE3 0UX Lead Inspector Keith Charlton Unannounced 4 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Agnes House Version 1.10 Page 3 SERVICE INFORMATION Name of service Agnes House Address Wyggestons Hospital, Hinckley Road, Leicester LE3 0UX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0116 2559174 Wyggestons Hospital Mrs Ellen Tebbutt Care Home 26 Category(ies) of Physical disability over 65 years of age -20 registration, with number places, Sensory Impairment over 65 years of of places age -5 places and Older People over 65 -26 places Agnes House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10/11/2004 Brief Description of the Service: Agnes House is registered under the Care Standards Act 2000 and has been providing care since 1992. Agnes House is a purpose built home set in five acres of landscaped gardens in the centre of Leicester. It is registered for twenty six service users within the categories of old age, not falling within any other category, physical disability and sensory impairment. Accommodation is on two floors and these can be accessed by a shaft lift. The home offers a large lounge-dining area on the ground floor, which leads to a large well-fitted conservatory and this leads into a sensory garden. A further lounge is situated on the first floor. All the bedrooms offer en-suite facilities and all rooms are served by an emergency call system. The home enjoys the facilities and activities offered by William House, a sheltered housing scheme that is built adjacent to the home. These facilities include a chapel, Library and large meeting room. Agnes House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 9.30 in the morning and finished at approximately 1.30 in the afternoon on the first day.The Inspector had a look around the Home and found that all areas were clean and tidy and there was no odour. The Inspector spoke to 9 residents in total who were very satisfied with the Home and how staff were very attentive, they knew how to complain if they ever needed to, they could go to bed and get up when they liked, they could go out and walk around the grounds or get staff to help them, about staff playing board games with them, about their Care Plans, that one resident had a kettle and fridge in her room and she was able to make drinks as she could safely do this. The only doubts they had was there were very few outings and they said that some residents would like these to be more frequent and go further, e.g. to the seaside and some residents queried whether they could have food between tea and breakfast the next day. Two staff were then spoken to about their training which covered lots of relevant areas such as how to safely move residents, first aid, Health and Safety, fire drill practice etc. Staff described in detail how two residents lived their lives in the home, their hobbies and choices and their care needs – this tallied with what residents had told the Inspector. Staff were asked as to what to do if they witnessed abuse of a resident. They knew to report it to Management and go further though they were unclear which outside Agencies to get in touch with if they were ignored by the Home. The Inspector then went into the kitchen and looked at the food for dinner and spoke to the cook. Dinner looked and smelled appetising with a choice of meal with two fresh vegetables and potatoes. The menu covered a range of meals. Residents with diabetes have a normal diet and sweets made with a low sugar alternative. From looking at the staff rota this showed three care staff plus Management on each day as well as a cook and a domestic worker. There are two awake staff at night. Medication and staff records were generally well kept. It was good to see a medication effects list so staff could easily check what medication was for and any side effects. The Inspector returned on 8/4/05 to complete the Inspection and meet the Registered Manager and the Home’s Deputy Manager, and had useful, professional discussions about the above findings. What the service does well: Service users reported that Staff and Management were very friendly and efficient, that the Home was kept very clean and tidy (this was verified by the Agnes House Version 1.10 Page 6 Inspector) in that their bedrooms were cleaned daily and laundry regularly changed, that residents were generally satisfied with the level of in house activities and that the food was very good. Staff were observed to be generally very conscientious and friendly in their dealings with residents. Care Plans contained a good level of detail as regarding residents individual needs, choices and preferences and had their life histories so as to give staff a more complete picture of them as individuals. Medication records had a list with them giving staff information as to what the medication was for and what their side effects were. Residents had the freedom to persue their lifestyles, e.g. a resident went to a outside beetle drive and returned after 10pm, residents often get up after 9am, residents able to do so can have kettles in their rooms and self medicate etc. There are frequent Residents Meetings, chaired by an outside person and very good, detailed minutes available to refer to. What has improved since the last inspection? What they could do better: To increase the number of outings offered and to ask if some service users would like longer day trips – e.g. to the seaside. To ensure that staff do not accidentally effect residents dignity by e.g. addressing them as ‘darling’ or ‘dearie’ etc. Agnes House Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Agnes House Version 1.10 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Agnes House Version 1.10 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The admission process is well managed and ensures that there is a proper procedure prior to people moving into the Home. This ensures that care needs can be met. EVIDENCE: The Manager stated that service users are only admitted into the home after a needs assessment has been undertaken by her or the deputy manager. This is to ensure that the identified needs of the prospective service user can be met at the home. All service users are offered a four-week trial period followed by a review. Two residents spoken with stated that this process occurred. The Home does not provide intermediate care facilities. Agnes House Version 1.10 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Care planning is in place to ensure residents needs are met. Residents dignity is not always protected – the Registered Manager is to act to ensure this area of practice is always met. EVIDENCE: Two care plans were looked at and it was noted that all had been reviewed on a monthly basis to ensure care is still appropriate. The Care plans looked at mostly included the assessed care needs of service users, and requirements made regarding the inclusion of falls risk assessments and continence management have been acted upon from the last Inspection Report. It was agreed with the Registered Manager that care staff need to be aware of residents Care Plans so that care practice is always consistent. Discussions with service users tracked indicated that they were generally aware of the existence of their care plan. Progress has been made on improving arrangements to ensure that the care needs of service users are identified and met. Agnes House Version 1.10 Page 11 Decisions are made by service users, which are recorded on their Care Plans. Evidence was seen of GP’s, community nurses and domiciliary services such as the chiropodist, dentist, and optician, visiting the home. The Registered Manager is to follow up with the optician whether anything can be done for the resident with difficulty in reading. Service users stated that they thought staff carried out personal care in a friendly and efficient fashion. As one resident now has dementia the Registered Manager is to set up training for staff on this subject. It was noted that that there was one instance where staff were observed not to knock before entering a service user’s bedroom, that service users were often addressed as ‘darling and ‘dear’ and that a service user was encouraged to say ‘good morning’ to a visitor, as an adult would encourage a child to do. The Registered Manager stated that these issues would be followed up so as to ensure service users dignity at all times. Agnes House Version 1.10 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 Residents have a high degree of choice in how they live their lives, unrestricted by rules. Social activities and meals are generally well managed. EVIDENCE: Service users were generally satisfied with the level of in house activities but a number stated that there were not enough trips out. This was checked and found to have been raised in a Residents Meeting of 26/1/05. The Registered Manager is to follow this up - a staff member stated that this was partly due to the difficulty of obtaining suitable transport. A programme of entertainment is offered at the home, this includes trips, external entertainers and activities provided at the sheltered accommodation next to the Home. A programme of events was seen on display detailing all of the activities planned for the month. Agnes House Version 1.10 Page 13 Activities Records inspected recorded recent activities attended by service users. Residents said that there were no rules and they could do as they pleased. All service users gave examples of staff empowering them and allowing choice – for meals, bathing and bedtimes, able to help keep their bedrooms tidy if able and willing to do so etc. A staff member commendably said ‘we are here for residents, not them for our benefit’. Meals and menus were inspected and the home was found to be offering a varied and nutritious diet. Records looked at demonstrated that weights were recorded regularly. Service users all said that the meals were well prepared and nicely presented with plenty of choice. Agnes House Version 1.10 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Service users can express their views and felt confident that if they have concerns these will be taken seriously and dealt with. Staff have a generally good grasp of how to report abuse but need to know how to contact all the main agencies. EVIDENCE: Agnes House Version 1.10 Page 15 The Registered Manager stated that no complaints had been received since the last inspection. The Commission for Social Care Inspection has also not received any complaints in relation to the Home. Service users asked indicated that they were aware of how to make a complaint and were confident that any complaint would be dealt with appropriately. At the time of the inspection both an abuse policy and a whistle blowing policy was in place and a copy of the Department of Health’s” No Secrets” policy was available for staff to read in the main office. On discussion with staff members on duty at the time of the inspection it was evident that all were generally aware of what to do in the event of suspected abuse in that they would report upwards in the Management chain if they thought that their concerns were not properly addressed though there was some uncertainty as to which outside Agencies they would contact if this was necessary. The Registered Manager said that a short procedural statement would be drawn up for staff to remind them of this procedure, and staff would also be verbally reminded. Agnes House Version 1.10 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,26 The décor is to a very good standard. The Home presents as a clean and pleasant environment. EVIDENCE: Agnes House Version 1.10 Page 17 Improvements to the décor of the home have taken place since the previous inspection. Improvements have also been made in relation to cleanliness of the home to ensure health and well being of residents. A tour of service users rooms was undertaken during this inspection and rooms inspected were found to be clean and tidy. Service users were very satisfied with their rooms and said they were able to accommodate their furniture and possessions, though this is dependant on space restrictions. Rooms were found to be personalised and attractive. The home is extremely well maintained both internally and externally. The decoration and furnishings throughout the home are both of a high standard and are presented in a comfortable and homely way. There is a lounge/dining room on the ground floor, which leads to a large airy conservatory. There is also a further lounge on the first floor. There is also a large reception area with seating available for service users to use for private meetings. All service user rooms are single and en suite. Service user’s case tracked indicated that toilets and bathrooms were appropriately placed to meet their individual needs. Braille signs are in place on toilet doors for service users with a sensory impairment. CCTV is installed for security purposes. Inspection of bedrooms and communal areas identified that appropriate disability equipment was in place, these included hoists, beds, grab rails. A call bell system is fitted in each room including communal areas and the Registered Manager has ordered pendants for residents needing a more accessible call system. Service users again made many positive comments about the gardens and conservatory. Ramps are in place in order that wheelchair users can access the gardens and summerhouse. Agnes House Version 1.10 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Staffing levels are as required and appear to be adequate for the needs of residents. The procedures for the recruitment of staff are generally effective. Training of staff is generally comprehensive and will meet all requirements once dementia training is provided to staff. EVIDENCE: Agnes House Version 1.10 Page 19 At the time of the inspection the registered provider was found to be complying with the care staffing guidance recommended by the Department of Health, Residential Forum Staffing Formula. Residents said that staff always answered call bells in good time. Observation of staff during this inspection identified that work with residents was carried out in a relaxed and friendly manner. Records seen indicate that the home has approximately 25 of staff trained to at least National Vocational Qualifications level two and that further staff will have completed or commenced National Vocational Qualifications level 2 /3 later in the year to achieve the 50 National Standard. 2 staff files were examined and files noted no unexplained gaps in the employment history, and evidence of a Criminal Records Bureau and Protection of Vulnerable Adults check. One staff record was without copies of birth certificate or passport, which the Registered Manager stated would be followed up with the Administrator. As the Home has a resident with dementia it was agreed there needs to be staff training on this issue. Agnes House Version 1.10 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36,37,38 The Registered Manager offers a clear sense of leadership which reflects on the day-to-day delivery of care of service users and running of the home. The outcomes in general have been positive for residents. EVIDENCE: Agnes House Version 1.10 Page 21 The home has an ongoing programme of Quality Assurance, which includes meetings for service users, and an annual satisfaction survey. Discussions with staff and inspection of staff records indicated that staff appraisals had been completed on staff. The Registered Manager had commenced staff supervisions as identified at the last inspection and that supervision of staff has now been formalised. The Registered Manager showed the Inspector supervisions that have taken place. These were slightly behind schedule and the Registered Manager showed evidence of Management staff soon to attend a course on supervision practice. This task will then be carried out by all members of the Management team, to ensure it is carried out at needed frequencies. Staff said they had not yet read all Care Plans for residents or the policies and procedures of the Home. Staff need to read Care Plans for residents and the policies and procedures of the Home so that there is always consistent practice. It was agreed this was necessary and the Registered Manager is to set up a system to ensure this happens – this needs to be checked at supervision. Agnes House Version 1.10 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x 3 2 3 Agnes House Version 1.10 Page 23 No 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. 3. Standard 10 30 36 Regulation 12 18 18 Requirement For staff to ensure that they always address residents appropriately. For staff to be trained in Dementia care. For staff to be appropriately trained and supervised, e.g. they have read and understood the Homes policies and procedures and residents Care Plans. Timescale for action Immediate 8/8/05 8/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 15 Good Practice Recommendations That the cook keep residents preferences in a written form to easily be able to refer to it and that residents who do not want meat to be offered a vegetarian alternative. Agnes House Version 1.10 Page 24 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park Enderby, Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Agnes House Version 1.10 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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