Inspection on 09/06/06 for Agnes House

This inspection was carried out on 9th June 2006.

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 39 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Agnes House 28/04/09

Agnes House 24/07/08

Agnes House 19/11/07

Agnes House 24/05/07

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Agnes House 11a Arthur Road Erdington Birmingham West Midlands B24 9EX Lead Inspector Llynn Woods Key Unannounced Inspection 9th June 2006 09:15 Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 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 DS0000067024.V299936.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000067024.V299936.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Agnes House Address 11a Arthur Road Erdington Birmingham West Midlands B24 9EX 0121 373 0058 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) Angel Care Homes Ltd Vacant Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years The home can care for 2 named service users who are over 65 years of age, which is outside the category of registration. 2 (MD(E)) The home must ensure that the changing care needs of the older service users can be met by the home and that these care needs remain under regular review. 13th February 2006 Date of last inspection Brief Description of the Service: Agnes House was previously two domestic properties, which have been modified and adapted. It is located in a residential area on the outskirts of Erdington and is convenient to local shops, colleges, transport and leisure facilities. Agnes House is owned and managed by Angel Care Homes Limited and the Responsible Person is Mrs Balver Bislar. The home is registered to accommodate up to 14 people with mental ill health. The residents are all male. All residents have a single room. The home has three lounges. One of these is equipped with a tea bar where residents can help themselves to drinks and snacks. The home is suitable for people with near full mobility. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, starting at 9.15 and lasting until 18.45 in the evening. There were 11 residents living at the home. The inspector had the opportunity to speak with the new owner, the acting manager and his deputy. The inspector also received 3 comment cards and a letter from residents’ families. Staff were helpful and fully cooperated with the inspection. The inspector observed direct care practice, spoke to three people who lived at the home and to two members of staff. She also toured the home and examined records relating to health and safety, care delivery and residents. The inspector wishes to thank the residents, staff and the new owner for the hospitality and cooperation shown during this inspection visit. The ownership of Agnes House has recently changed and Angel Care Homes Limited now owns the home. The company have inherited many issues associated with pre-existing environmental and operational problems. This report therefore contains a high number of unmet requirements from previous inspections. However, this fact should be viewed in the light of significant action that has been taken or is planned by the new owners towards improving the environment, recordings and practice at the home. What the service does well: What has improved since the last inspection? There is now written information to help residents and referring authorities make informed choices about whether to live or make placements at the home. Pre-admission assessments have been prepared. Residents meetings and staff meetings have recently started to take place and there are also regular management meetings to evaluate action and to plan improvements to the service. New care plan and health monitoring formats are being introduced and staff say they are more actively involved in the preparation of care plans. Medication recording has improved significantly and the inspector could easily check the medication against records. Some areas of the accommodation have been improved and redecorated but action is far from complete. The new owners have prepared a schedule of works for maintenance and general improvement of the living areas. Formal staff supervision has taken place and there is a written plan for future dates. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 7 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 DS0000067024.V299936.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Information to assist residents make informed choices about the home is in place and there are arrangements for new pre-admission assessments and for service user contracts, but these are yet to be tested in practice. EVIDENCE: The new owners have produced an up to date statement of purpose setting out aims, objectives and philosophy of the home. There is also a newly developed service user guide to the home. On reviewing the statement of purpose and service user guide it was noted that the smoking policy differed between the two documents and the home should ensure information in the two texts does not conflict. A pre-admission assessment and general information was seen on sampled files, but the assessments seen were brief and did not fully detail assessment of need. However, the new owner shared a recently developed pro-forma that the home intends to apply for all new referrals for admission. Progress on full pre admission assessment will be tested at future inspection. The home is in the process of reviewing and rewriting standard service user contracts. There are reported plans to replace existing contracts when the documents have been finalised and shared with service users and placing authorities. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Overall the arrangements for individual care planning, service user decision making and risk taking are incomplete and omissions could compromise positive outcomes for residents. EVIDENCE: There has been some progress in the development of care plans and risk assessments over previous inspection findings. The home is actively in the process of completely updating all residents’ individual files into a new format but this task is not complete. Problems identified by previous inspection are still evident in some updated files. For example, it was noted a care plan had not been updated to reflect change in presenting need and no care plans appeared to have been reviewed on a monthly basis. Also an individual risk assessment was incomplete as the characteristics of mental health relapse, how relapse prevention was to be managed and at what stage external agencies were to be contacted was unclear. Other care plans did not fully detail how staff were to care and support the resident. The acting manager and new owners are aware of the issues relevant to care planning and reported plans for intensive staff training in this regard. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 10 A service user explained to the inspector how and in consultation with his community psychiatric nurse, the home helped him to budget and manage his money. However, it was impossible to evidence how residents were assisted to manage their finances. This was due to the records and arrangements for the home holding for safekeeping and managing service user finances being totally inadequate. The new owners are acutely aware of the serious issues concerning the management of service user finances. It was explained to the inspector that the previous manager had only recently handed finances to the new owners and that the home was now urgently developing an appropriate financial management system. Recordings showed residents were enabled and assisted to undertake risk activities but generally risk assessment, the homes response to risk events and subsequent decision-making was not adequately detailed or recorded. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Residents live in a home where their rights are recognised and respected, where they are able to enjoy a positive lifestyle of their own choosing and where nutritional needs are met. EVIDENCE: The home encourages and supports full social inclusion and a number of residents were assisted to access community facilities on the day of inspection. Other residents said that they occasionally went out to snooker halls, cinemas, shopping precincts and local shops. Some residents spend time tending the homes’ garden where they grow vegetables, flowers and fruits. An assessment of education and employment needs is made upon admission this information was also recorded on some social work care plans. The home supports some residents to attend day centres. However, several residents did not appear to be gainfully occupied during the inspection and some also said that they didn’t do anything all day apart from watch television. Residents said that they are supported and assisted to maintain contact with people who are important to them and family and friends could visit at the home. They also have unrestricted access to the home and the grounds, Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 12 although they do not have a key to the front door. Some bedrooms were found to be unlocked when the resident was not at the home. On checking locking mechanisms it was apparent that, with a few exceptions, the locks on the bedroom doors had been disabled. The acting manager explained most residents did not want a key for their rooms, but this choice was not evidenced in care plans or recordings. Staff and residents interacted readily and spontaneously and the atmosphere of the home was easy and relaxed. Observation of interactions supported the homes clear ethos of dignity and respect towards residents. A mealtime was not shared with residents but staff reported meal timings were flexible and based upon individual needs. Residents also said they could prepare snacks and drinks whenever they wanted between meals. As many residents are out of the home during the day the main meal is served after 4pm. Breakfast is served as residents get up from bed and this includes a choice of daily cooked breakfast. Lunch is mainly hot snacks or sandwiches and some residents have lunch at day centres. There is now a stated choice of evening meal and residents are asked to nominate their choice the night before. Review of previous menus showed the home serving varied and nutritionally balanced meals and residents said that the food was always good. However, assessing the nutritional balance of meals served was not easy and the acting manager said that staff were considering how to streamline the recording sheets whilst still maintaining information. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Although arrangements to meet health needs of residents are improved above previous inspection findings, residents still do not have their health care needs adequately assessed or met. EVIDENCE: It was evident from some recordings and staff reports that residents are provided with sensitive and flexible personal support but this is not adequately described or recorded within all care planning documentation. However, the home is actively introducing new care plan formats and the efficacy of these new documents will be assessed at the next inspection. Systems to monitor and record residents health care needs were under review and the home was in the process of introducing a new format for recording health related information. However this task was not complete and on reviewing file recordings it was noted that the information on the new format served as more a log of information as opposed to a health care plan per se. This was discussed with the acting manager and deputy and the home now has plans for further development. Most residents’ medicine is managed by the home. The management of medicines was sampled for two residents and it was possible to undertake a full audit of these residents medication. Where residents’ self-administered Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 14 medications there were no risk assessments and compliance checks had not been completed. Although staff were aware of how, when and in what circumstances to administer medication, practice is not underpinned or informed by adequate written policy and procedure. The home has yet to acquire a controlled drug register and there are no written protocols for the administration of ‘when necessary’ or ‘as directed’ medications. Staff were not aware of the common side effects of the medications given to residents. At one point during the inspection the inspector went to the office and found the keys in the office door lock. Inside the office the medicine cabinet was open and the rear exit doors from the office were also wide open. During audit one medication was not in the cabinet and was found in an unlocked drawer. It was reported that staff have received accredited training in the management and administration of medication but training records were not available to evidence the training. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents are knew and were comfortable about using the complaints procedures but overall they are not adequately protected from possible abuse and in particular the management of their money is not transparent, auditable or safe. EVIDENCE: Residents said that they were aware of how to go about complaining if they were unhappy about any aspect of their care experience at the home. The homes policy for residents and representatives complaints is visible in the home. There is a log of complaints but there are no recent recorded entries. Over the last 12 months the commission has not received any complaints in respect of the home. It was reported that most staff have been trained in adult protection procedures and protecting vulnerable adults. But training records were not seen to evidence this. The home has still not updated the adult protection policy to include immediately contacting Social Care and Health to refer under adult protection procedures - notifying the commission - making the immediate situation safe and providing the details of organisations who can offer support to victims. Staff have not had training in techniques for physical restraint or breakaway moves. The homes arrangements for residents’ monies are inadequate and place residents at risk of financial abuse. This is referred to above at page 16 in the section ‘Individual Needs and Choices’. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Although improving the environment in some areas of the home is inadequate to meet the individual and communal needs of residents. Certain areas put the health and welfare of residents at risk. EVIDENCE: For some considerable time and as reported following previous inspection, large areas of the home and its décor, fixtures and fittings have been in need of upgrade and/or refurbishment. Although a high number of previous requirements remain outstanding, the new owners have begun to address deficiencies in the fabric and environment. In addition the Commission has also been provided with a copy of the owner’s schedule of works relating to maintenance and renewal for the whole premises. There are a range of toilets and bathrooms available on all floors, some baths have an overhead shower and the first floor has a walk in shower unit. Most toilets, bathrooms and bedrooms had inadequate privacy locks. Flooring in some areas did not fit to the skirting board or was missing and did not aid effective cleaning. Cleanliness and odour control in some areas was inadequate and particularly a bedroom smelt strongly of urine and a toilet and its surrounding area was dirty and smelt offensively. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 17 The home has still not purchased a washing machine with a sluice cycle (to reduce the risk of spread of infections). Tablet soap was noted in some communal bathrooms and the hoist seat in the ground floor bathroom had not been serviced or adequately maintained. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Residents are cared for by adequate numbers of staff but staff have not been adequately trained to meet the needs of the residents. EVIDENCE: Staff were able to describe and define their roles, duties and responsibilities and the roles of others. The acting manager said that the home was still in the process of developing new job descriptions for all staff and these would be placed on individual files when they had been shared and agreed with staff. The new owner states a strong commitment to staff training. He said a training and development plan would be devised following completion of analysis of training needs. This analysis was nearing completion. It was therefore not possible to fully evidence the competence or training of staff. However, it would appear from an analysis dated 12/08/06 that staff have not received specific training in mental health and of the current 13 established staff (the previous owner is still included in the staff training record) 4 staff hold NVQ level 2 (31 ). However no certificates or other evidence was seen to support this. The staffing rota has been amended to state the hours worked by staff. The roster and actual staffing on inspection showed sufficient numbers of staff on duty to care for residents living at the home. Staff confirmed formal Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 19 handovers between shifts were always now conducted and that there was never only one member of staff on duty. 3 staff files were sampled and these had recent photographs of the staff but there was still no health declaration or evidence of health screening. Since taking over the home the new owner has implemented a schedule of formal staff supervision. The first supervision sessions took place in June and there is also a monitoring form to track when supervision happens and if it is cancelled the reason why. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Management arrangements are more integrated but there is currently no system for effective quality monitoring and health and safety practice is failing to ensure health and safety needs of residents and staff. EVIDENCE: There is currently an acting manager in post who reported having appropriate qualifications and experience suited to the role. However, no written evidence of qualifications, recent training or the acting managers job description was reviewed. The new owner said that he was actively developing a tool for selfmonitoring the homes operation against its aims and objectives but there was no evidence of provider visits under Regulation 26. With some notable exceptions the home was taking steps to protect residents, staff and visitors from hazards. At the last inspection the home was required to develop risk assessments for the premises (including the garden), staff and food and to implement a comprehensive fire risk assessment. The acting manager said that this had not as yet been completed. Several fire doors upstairs were also noted to have been left wedged open. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 21 Records showed staff and residents were involved in fire drills and fire prevention tests were regular and up to date. However there was no evidence of service to the fire alarm system, compliance check of the gas installation, service to the bath hoist/chair, 5 year wiring check or risk assessment or action relating to the risk of Legionella. On touring the premises it was noticed that a fire exit route was obstructed, a fire exit door was damaged, COSHH items were unsecured and a step down to the garden area was loose. At a follow up visit on 12/06/06 repairs had been affected and the fire exit route was cleared. The main kitchen requires upgrade to ensure adequate and hygienic food preparation and although the new owners have identified this area for refurbishment by 31/01/2007 they should consider promoting that schedule to an earlier date. Food storage and stock rotation was not entirely compliant to good food hygiene practice as there were out of date carrots and sprouting potatoes in the storage area. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 22 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 2 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 2 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 2 X X 2 X Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 23 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 YA1 Regulation 4(1) 1 5(1) 14(1)(a) Requirement The statement of purpose and service users guide must be amended to ensure information in the documents does not conflict. The pre-admission assessment document must be completed for all new admissions. There have been no new admissions to assess compliance with this requirement and it is therefore carried forward. Details of pre-admission visits and assessments by residents must be available at the home. There have been no new admissions to assess compliance with this requirement and it is therefore carried forward. Written care plans must be fully reviewed on a monthly basis and involve the residents. The assessments of needs must be routinely reviewed on Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 24 Timescale for action 31/07/06 2 YA2 09/06/06 3 YA4 12(1)(a) 14(1) 09/06/06 4 YA6YA18 12(4)(a) 15(1)(2)b 14(1)2a 30/06/06 a six monthly basis and involve the resident. Daily reports must record information regarding how effective or otherwise residents plans have been. Previous timescale of 30/4/05 not met this requirement is carried forward. Care plans must be written in consultation with residents, the plan must inform staff of how they will meet the needs of residents. All risk assessments and the associated management plans must be reviewed on a monthly basis with the resident. Previous timescale of 31/07/05 not met this requirement is carried forward. Risk assessments must be fully developed and implemented to identify the mental health needs of residents and must include early warning indicators of relapse and inform staff of what they must do. The system of risk assessment must adequately identify the level of risk and include proportionate strategies to effectively manage the risk. Previous timescale of 28/02/05 not met this requirement is carried forward. Health care plans and risk assessments must be in place for epilepsy, challenging DS0000067024.V299936.R01.S.doc 5 YA6 15(1) 30/06/06 6 YA9 13(4) 30/06/06 7 YA9 12(1) 13(4) 23(4) 31/07/06 Agnes House Version 5.1 Page 25 8 YA12YA14 12(1)(a) 15(1) 9 YA16 12(4)(a) 10 YA17 16(2)(i) behaviours and fire safety (with specific detail about safe smoking), all risk assessments must include measures that are taken to reduce identified risks. Residents who choose to 31/07/06 remain predominantly within the home during the day must have an individual plan of activity developed and put into practice in respect of their choices and abilities. The home must ensure 30/09/06 service users are able to secure their personal belongings in their bedrooms and suitable locks are fitted to bedroom doors, service users are offered a key to the lock and (subject to risk assessment) to the front door of the home. The home must ensure that 31/07/06 an alternative meal is available and recorded on the menu for dinnertimes. The home must ensure clear records of meals are maintained and that menus are nutritionally balanced Residents must be provided with healthy food, where their preference creates a health risk, a risk assessment must be implemented. The environment in the kitchen must be improved to ensure food is prepared and cooked safely. Fridge and freezer temperatures must be monitored and recorded ensuring food is safely stored. Previous timescale of 11 YA17 16(2)(i) 12(1) 13(4) 28/06/06 Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 26 12 YA19 12(1) 13(4) 15(1) 28/02/05 not met this requirement is carried forward. The healthcare needs of residents must be fully monitored, changing needs must be assessed and appropriate care plans developed. Records must be maintained detailing when residents have appointments with healthcare services including outcomes where possible. The home must have an appropriate register for controlled drugs to ensure safe management. The home must fully develop a medicine policy that reflects all current practice. Previous timescale of 28/02/06 not met these requirements are carried forward. Residents who self-administer medicines must have a risk assessment completed and regular compliance / safety checks carried out. The home must ensure consistency in administration of PRN and as ‘directed medications’ and must develop written protocol informing when and in what circumstances these medications should be given. The home must ensure all staff administering prescription medications are aware of the common side effects associated with the medication. At all times the medication DS0000067024.V299936.R01.S.doc 31/07/06 13 YA20 13(2) 28/06/06 14 YA20 13(2) 30/06/06 15 YA20 13 31/07/06 16 YA20 13(2) 09/06/06 Page 27 Agnes House Version 5.1 17 YA23 18 YA23YA7 19 YA23 20 YA24 21 YA24 22 YA24 23 YA26 cupboard and staff office must be secured when staff are not in the immediate area. 13(6) The registered person must ensure the Adult Protection policy complies with guidance given in the Multi Agency Guidelines, and DOH document No Secrets. See standard 23 for further guidance. Previous timescale of 31/03/06 not met, this requirement is carried forward. 13(4)(c) Accurate records of residents’ 13(6) money management must be maintained, including signatures to confirm transactions. Previous timescale of 13/02/06 not met, this requirement is carried forward. 13(4)(c) The home must ensure staff 18(c) are appropriately trained in safe techniques for physical restraint and in breakaway techniques. 23(2)(b)(c)(d) Sash windows in communal areas that have been painted over and do not open must be repaired. Previous timescale of 31/03/06 not met, this requirement is carried forward. 23(2)(b) Windows and window frames 13(4) that are damaged and or ineffective must be repaired or replaced. 16(2)(k) The home must ensure all 23(2)(d) areas are kept clean and the home is free of offensive odour 12(4)(a) En-suite doors must have appropriate privacy locks that can be easily overridden in an DS0000067024.V299936.R01.S.doc 30/06/06 13/06/06 30/09/06 30/06/06 30/09/06 30/06/06 31/07/06 Agnes House Version 5.1 Page 28 24 YA27 12(4)(a) 13(4) 25 YA30 13(3) emergency. Previous timescale of 31/03/06 not met, this requirement is carried forward. All toilets, bathrooms and shower rooms must be fitted with appropriate safety locks. Previous timescale of 31/07/06 not met, this requirement is carried forward. Tablet soap when used by residents in communal bathrooms must be returned to their rooms. The hoist seat in the bathroom must be kept clean and hygienically maintained. Previous timescale of 31/03/06 not met this requirement is carried forward. An action plan must be submitted to indicate when a washing machine with a sluice cycle (to reduce the risk of spread of infections) will be provided. Previous timescale of 31/03/06 not met, this requirement is carried forward. All staff must be provided with a description of their job. Previous timescale of 31/03/06 not met this requirement is carried forward. The home must have a minimum of 50 of the care staff qualified to NVQ level 2 in Care. Previous timescale of 30/04/06 not met, this requirement is carried forward. DS0000067024.V299936.R01.S.doc 30/06/06 31/07/06 26 YA30 13(3) 16(2)(j) 31/07/06 27 YA31 17(2) 4(6)(e) 30/09/06 28 YA32 18(1)(c )(i) 30/06/06 Agnes House Version 5.1 Page 29 29 YA34 19(1)(b)i 2(1)(6) 30 YA35 18(1)(c)(i) Staff files must include evidence of health screening. Previous timescale of 28/02/06 not met, this requirement is carried forward. All staff must receive service specific training. Previous timescale of 31/03/06 not met, this requirement is carried forward. 28/06/06 30/09/06 31 YA39 24(1) 32 YA39 26 33 YA42 13(4) 23(2)(o) The home must have a training and development plan and an individual plan for each member of staff following a training needs assessment. Previous timescale of 31/03/06 not met, this requirement is carried forward. The home must implement a 30/09/06 system of self-monitoring assessment to determine its performance against its goals and objectives. Previous timescale of 30/04/06 not met, this requirement is carried forward. The registered provider must 30/06/06 ensure Regualtion26 provider visits and reports are completed consistent to statutory obligation. Risk assessments must be 31/07/06 completed for the premises, staff and food. A fully comprehensive fire risk assessment must be completed and shared with staff and residents. Previous timescale of 17/02/06 not met this requirement is carried forward. DS0000067024.V299936.R01.S.doc Version 5.1 Page 30 Agnes House 34 YA42 23(4) 13(4) The garden must be included within the premises risk assessment, and also cover maintenance issues. Previous timescale of 31/03/06 not met this requirement is carried forward. The home must arrange for 30/06/06 appropriate service/checks to: Fire alarm installation: Bath hoist/chair: Gas installation: Electrical wiring: The home must also arrange for risk assessment and appropriate action relating to Legionella. Evidence of action regarding the above must be sent to CSCI. The home must ensure: Fire doors are never wedged open: COSHH items are securely stored: Fire exits are clear of obstruction at all times: Adequate stock rotation of foodstuffs. Hand wash soap, paper towels and lidded bins must be available at all hand wash areas. 35 YA42 13(4) 09/06/06 36 YA42 13(3) 10/06/06 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 YA42 Good Practice Recommendations It is recommended that the home provide a minimum of DS0000067024.V299936.R01.S.doc Version 5.1 Page 31 Agnes House two waking night staff. Agnes House DS0000067024.V299936.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 DS0000067024.V299936.R01.S.doc Version 5.1 Page 33 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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