Inspection Report - Care Quality Commission...2014/09/11 · |Inspection Report | Agape House Limited | September 2014 4 Summary of this inspection Why we carried out this inspection

| Inspection Report | Agape House Limited | September 2014 www.cqc.org.uk 1

Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Agape House Limited

45 Maidstone Road, Chatham, ME4 6DG Tel: 01634841002

Date of Inspection: 18 November 2013 Date of Publication: September 2014

We inspected the following standards as part of a routine inspection. This is what we found:

Consent to care and treatment Enforcement action taken

Care and welfare of people who use services Enforcement action taken

Cleanliness and infection control Enforcement action taken

Management of medicines Enforcement action taken

Safety and suitability of premises Enforcement action taken

Supporting workers Enforcement action taken

Assessing and monitoring the quality of service provision

Enforcement action taken

Notification of death of a person who uses services



Details about this location

Registered Provider Agape House Limited

Registered Manager Mrs Beverly Keith

Overview of the service

Agape House Limited is a care home situated in Chatham, Kent. Accommodation and personal care is provided for up to 20 older people.

Type of service Care home service without nursing

Regulated activity Accommodation for persons who require nursing or personalcare


Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

What we have told the provider to do 5

More information about the provider 5

Our judgements for each standard inspected:

Consent to care and treatment 6

Care and welfare of people who use services 8

Cleanliness and infection control 11

Management of medicines 13

Safety and suitability of premises 15

Supporting workers 16

Assessing and monitoring the quality of service provision 17

Notification of death of a person who uses services 19

Information primarily for the provider:

Enforcement action we have taken 20

About CQC Inspections 24

How we define our judgements 25

Glossary of terms we use in this report 27

Contact us 29


Summary of this inspection

Why we carried out this inspection

This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 18 November 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and were accompanied by a specialist advisor.

What people told us and what we found

We found that people's consent to care had not always been obtained and recorded. In one case we found no evidence of consent, no mental capacity assessment and no recordof best interest meetings held on the person's behalf.

People we spoke with told us"The staff are very good" and "I don't think they could do anything better for me".However, we saw that risk assessments had not always been carried out when appropriate. Scoring tools used to identify people's level of risk had been incorrectly added up by staff in some cases, giving inaccurate results.

We found that there were not effective systems in place to prevent the spread of infection. Standards of hygiene were observed to be inadequate and some equipment could not be properly sanitised.

Medicines had not been stored safely within the service and the administration and recording of people's medicine was not always completed appropriately.

We observed that the premises was poorly lit and in need of maintenance and redecoration to keep it safe and pleasant for the people living there.

Staff had received some training but we found that none had been given in identifying pressure areas and using risk-measuring tools correctly and effectively.

The most recent survey conducted by the service received comments such as' Very happywith the care'.However, staff views of the service were not always considered.

You can see our judgements on the front page of this report.


What we have told the provider to do

We have referred our findings to Local Authority: Safeguarding. We will check to make sure that action is taken to meet the essential standards.

We have taken enforcement action against Agape House Limited to protect the health, safety and welfare of people using this service.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service(and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phrases we use in the report.


Our judgements for each standard inspected

Consent to care and treatment Enforcement action taken

Before people are given any examination, care, treatment or support, they should be asked if they agree to it

Our judgement

The provider was not meeting this standard.

People were not always asked for their consent before receiving any care or treatment.

We have judged that this has a moderate impact on people who use the service and have taken enforcement action against this provider. Please see the 'Enforcement action' section within this report.

Reasons for our judgement

Where people did not have the capacity to consent, the provider did not act in accordance with legal requirements.

We read the care files for four of the people who used the service and saw that signed consent forms were in two of them. These forms related to consent for medicines to be administered, preference for care to be given by male or female staff and authorisation to discuss care needs. However, these forms were not always present in all of the files we checked. This meant that the provider could not show that they were consistently acting in accordance with people's consent and wishes in relation to their care and treatment.

In one of the care files we reviewed, we found no signed consent forms at all. The manager and staff told us that this person lacked capacity to give consent. There was no mental capacity assessment or information about the different types of decision that this person might need help with. The manager was unable to provide us with evidence of any meetings with relatives and/or professionals to discuss what would be in this person's best interests. This meant that the provider could not show that this person's rights had been protected.

We read training records provided to us by the manager which showed that nine out of 17 staff had received training about the Mental Capacity Act; but that this training had lapsed for four of the nine staff. This meant that only five staff had current and up-to-date training about this subject. The Mental Capacity Act sets out a clear process for accessing people's mental capacity and recording any decisions made on their behalf. The staff we spoke with did not have a clear understanding of their roles and responsibilities when people lacked capacity. Suitable arrangements were not always in place for obtaining


people's consent and acting in accordance with it.


Care and welfare of people who use services Enforcement action taken

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement


Care and treatment was not planned in a way that was intended to ensure people's safety and welfare.

We have judged that this has a major impact on people who use the service and have taken enforcement action against this provider. Please see the 'Enforcement action' section within this report.


Care and treatment was not planned in a way that was intended to ensure people's safety and welfare.

During the course of our inspection, we observed that staff were kind and respectful when speaking with the people in their care. We saw that interactions were gentle and caring and we saw staff taking action to protect people's dignity.

We spoke with three people who were using the service. One person told us "I like my room and I have no complaints". Another person said "The staff are very good" and " I don't think they could do anything better for me". We observed people having a short sing-along with staff but apart from this people were either sleeping or watching TV in the lounge. One relative we spoke with said :"There's a lack of stimulation for people-no activities". We looked at activities plans and records and found that people had been offered very little organised activity. One person's activity plan only listed visits from family members since August 2013. In July the plan recorded 'Rubix cube' on one occasion. Another person's activity plan recorded one activity each week which was generally watching a film or a sing-along. We looked at this person's care plan and read 'Likes to joinin all activities-staff to encourage to join in'. We asked the manager about this and we weretold that, although organised and scheduled activities had been run in the past, the provider had recently stopped these. Staff were now expected to engage in sing-alongs or similar when they were able to. People's individual needs for stimulation had been assessed but were not being met by the provider.

We read four care files during our visit and found that the level and quality of information about people varied between them. Some of the care plans recorded people's preferencesabout times for getting up and going to bed while others gave no information about people's preferred daily routines. We found no information in any of the care files we checked about people's past histories, their interests or hobbies. This showed that


people's personalities and choices had not been properly considered in delivering their care.

We found that assessments had been carried out to identify people at risk of developing pressure areas or skin problems. However we saw that scoring tools that were used to assess the level of risk to people, had sometimes been added up incorrectly. In one case we looked at, this mistake had the effect of halving the total score for a person who had developed skin wounds. We asked staff about this and they explained that they had not received training in how to use the scoring tool.This meant that there was a risk that staff would not recognise the true level of risk to people and might not take appropriate or timelyaction to protect their care and welfare.

We read other information about people's skin integrity in the care files. One person's last review was written on 26/9/13 at which time staff had recorded skin 'Currently intact'. However, we read records of district nurse involvement which showed that this person hadhad a number of skin problems that had not been reflected in the updates written in the care files; most recently in November. These consistently read 'Skin intact' even though this person had had a number of different skin wounds during the period covered by the updates.There was no information in the care file about the nature of one of these wounds or its cause.This meant that the skin integrity risk assessment and reviews were not fit for purpose as they did not present an accurate picture of the person's conditions and needs and meant that people were at risk of receiving inappropriate care from staff. Another person had a skin integrity risk assessment in their care file which stated that they should be turned every two hours throughout the day and night on the advice of the District Nurse.We read turn charts for this person and found that this had not always been carried out consistently.One one date, there were no notes to show that this person had been turned until 20:50 hours in the evening. On another occasion,there was no evidence that this person had been turned between 08:30 and 12:30.There was gap in the records of turns that we were shown between 20:00 on 29/10/2013 to 22:00 on 31/10/13. Staff we spoke with were unable to offer an explanation for this.Since the date that two-hourly turns had been instructed by the District Nurse, this person had developed further areas of sore skin.This showed that people's care and welfare had not been adequately protected by theprovider.

Scoring tools had also been used to identify people at risk of poor nutrition. Staff told us that they had not received training in the use of these tools. We read the most recent scorefor one person dated 30/9/13 which, when added up, showed them to be at 'Low risk'. We checked the adding up and saw that this was incorrect because the Body Mass Index (BMI) score had been wrongly copied from a chart in the care file.This person's score should have shown them at 'Medium risk'.This person's care plan about nutrition, stated that the required outcome was 'To ensure they enjoy their food and don't lose weight'.We checked this person's weight records and noticed that they had lost weight between July and November 2013. The nutrition risk assessment for this person had not been updated to show the weight loss and the low risk scoring was almost two months out of date. We read that this person ate well at breakfast but little at other mealtimes but there was no evidence that a dietician or doctor had been consulted about this. Daily care notes recorded this person's food intake on some occasions but this was not consistent. The wayin which amounts eaten were recorded, for example '¼ of lunch' and ' 1/3 of soup' meant that staff could not accurately tell how much and what type of food had been eaten. This meant that staff would not be in a position to pass accurate information about this person'snutrition to professionals if it became necessary.


We read weight records for a person who had been referred to a dietician following unplanned weight losses.Records showed that the dietician had prescribed a nutritional supplement to be given three times a day. We checked food diaries for this person but sawthat the supplement had often not been given three times a day and often only once.We spoke with senior staff about this who said that they gave the supplement when they believed it to be necessary and not always three times per day.The weight records showedthat this person had not put on any weight since the introduction of food supplements.This showed that, although professional advice had been sought, it had not been followed by the service;placing this person at risk of poor nutrition.

The manager told us about two people who sometimes showed challenging behaviour. Weread the care files for these people and found that there were no risk assessments in placeto help staff identify any triggers. Neither was there any guidance about preventative measures or ways of addressing the behaviours. One of these people had been prescribed a sedative but there was no information or advice about its use in the care plan.We also noted that there was no risk assessment in place for a person who the manager told us, was unable to use their call bell; although we did see that hourly check sheets had been completed for this person. People's needs had not been adequately assessed to enable care and treatment to be delivered in line with their individual care plan.


Cleanliness and infection control Enforcement action taken

People should be cared for in a clean environment and protected from the risk of infection

Our judgement


People were not protected from the risk of infection because the appropriate guidance hadnot been followed.



Effective systems were not in place to reduce the risk and spread of infection.

As part of our inspection we toured the home and found used latex gloves in open waste baskets in people's bedrooms. We saw that either swing-top or open bins were in use in most of the en suite bathrooms. This meant that people were at risk of the spread of infection from gloves used during personal care and the used paper towels and other items disposed of in their bathrooms.

We observed that a carer did not wear an apron while delivering personal care; which included dealing with incontinence of faeces.The carer did not wash their hands after removing the gloves they had worn to carry out these tasks. This was not an appropriate standard of hygiene and meant that staff and people using the service were at risk of infection being spread. We read staff training records which showed that seven out of 17 staff had received basic infection control training. However, this training had lapsed for fourstaff meaning that only three members of staff had current and up-to-date training in this subject.

We found that one bedroom had a strong odour and that the divan base was heavily stained. We asked the manager about this and they told us that the stain had been causedby urine. We noted that the standard mattresses in use at the service had thick plastic, non-breathable covers. Some of these covers were cracked and posed a risk of harbouring bacteria as they could not be effectively cleaned and sanitised. We saw that the duvet cover on one person's bed had the name of another person written on it in laundry marker. The sharing of people's bedding was not appropriate and placed people atrisk of infection being passed between them.

We checked the laundry arrangements in the service and observed that dirty clothing and bedding was placed directly onto the floor by the washing machine. This meant that


bacteria from the washing was not contained and could spread within the laundry. Staff explained that they used to use laundry baskets to contain the dirty washing but that these were all broken and unusable. We saw one basket in the laundry room that was falling intopieces. Clean washing was stored on open shelves and was therefore exposed to sourcesof contamination. The laundry room walls had areas of chipped paint which meant that they could not easily be cleaned to an appropriate standard. We read the Infection Control policy for the service but saw that this did not include guidance about the management of laundry. These factors showed that people and staff had not been protected from the risk of cross-contamination and the spread of infection because effective systems were not in place to reduce these risks.


Management of medicines Enforcement action taken

People should be given the medicines they need when they need them, and in a safe way

Our judgement


People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

We have judged that this has a moderate impact on people who use the service and have taken enforcement action against this provider. Please see the 'Enforcement action' section within this report.


Medicines were not safely administered and appropriate arrangements were not in place inrelation to the storage and recording of medicine.

At the start of our inspection we observed that the medicines trolley had been left unlocked, open and unattended in the lounge area. Staff later showed us that the locks were broken on two of the cupboards which formed the trolley. We also observed staff during the lunch time medicines round and noticed that the door to the medication room was left open and unlocked during the round. During a tour of the home we found that one person had four containers of a prescribed cream in their bedroom. None of these were kept in cupboards and were left out on surfaces in the room. We looked at the medicines fridge and saw that temperature recordings had not been made on a daily basis. On the day of our inspection, the last temperature recording had been made on 7 November 2013. Prior to this, the most recent recording had been made on 8 August 2013. This showed that medicines were not being safely stored by the service.

We checked the controlled drugs (CD) and register. We found that the register had been correctly maintained and totalled. However, we noticed from the register that one person had been consistently given 5ml doses of a medicine which had been prescribed at 2.5 ml doses. We saw that the person had had only one dose in a 24 hour period on each occasion. Both the dispensing label and the medication administration record (MAR) for this medicine sated that 2.5 mls could be taken up to four times per day. We asked the manager about this and they explained that this medicine was PRN,(to be taken as and when needed). The manager contacted us after our visit to state that they had sought the advice of a pharmacist about this issue. The manager reported that the pharmacist said that this person could take up to 10mls in a 24-hour period. This meant that the person had not received overdoses of medicine because they had received 5 mls in 24 hours. However, the instructions on the MAR sheet and dispensing label had not been followed by staff. In the event that 5mls had been given for the maximum four doses per day,


double the prescribed amount would have been administered.

We reviewed the MAR sheets for other people using the service and found further examples of when the dispensing instructions had not been followed. One person's medicine was shown on the MAR as '10mls on alternate days' but it had been repeatedly administered to them on consecutive days. Another person had tablets prescribed at 'one tablet twice a day' but the MAR sheet showed it had only been given at night time. Medicine recorded on the MAR sheet as being prescribed as one dose to be taken three times daily had 'Morning only' handwritten on the sheet with no explanation. Another person's had tablets on the MAR sheet recorded as 'Two tablets to be taken at night' with a handwritten note on the MAR sheet to say 'Mondays only'. We asked staff about these alterations to prescribed doses but they were unable to provide us with evidence that the changes had been directed by a doctor. This meant that the provider could not show that people had received their prescribed medicines appropriately.

Where people had PRN medicines prescribed to them, the MAR sheets had not been completed to show that the medicines had been offered or declined. For example, one person had PRN paracetamol prescribed at one to two tablets per day. The MAR sheet relating to this was completely blank so it was not possible to tell whether this person had been offered their medicine. MAR sheets use a system which allows staff to record a different code to show that medicine has been administered or refused. This system had not been used by staff and therefore the recording of medicine administration was inappropriate.

We read the training records provided to us by the manager. These showed that four staff had received training in 'medication' but of these four, training had lapsed in all but one case. This meant that the provider could not be sure that staff remained competent to administer medicines to the people using the service.


Safety and suitability of premises Enforcement action taken

People should be cared for in safe and accessible surroundings that support their health and welfare

Our judgement


People who used the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises.



The provider had not adequately maintained the environment.

During our visit we observed that the lighting in many of the communal areas was very poor. The people using the service were all elderly and many had restricted mobility and used aids to move around the home. Although some light bulbs were being changed on the day of our inspection, we spoke with a relative who told us that the home was always "so dark".This meant that people who used the service were at risk because of the inadequate levels of lighting.

We saw a raised area in the floor of one of the hallways. This had coloured sticky tape around the edges but it had rucked up creating a trip hazard for staff, visitors and people using the service. In one en suite bathroom we found missing floor tiles and an exposed threshold strip with sharp edges. There were also tiles missing from a wall in a communal bathroom and these had been balanced on the end of the bath.

A tour of the premises showed that there were holes in some bedroom walls, chipped paintwork and exposed pipework in several areas and broken door handles in others. Overall the premises were in need of redecoration to improve its appearance for the people living there. We spoke with a visitor to the service on the day of our inspection, whowas critical about the state of decoration. People had not been protected against the risks of unsafe or unsuitable premises because it had not been adequately maintained by the provider.


Supporting workers Enforcement action taken

Staff should be properly trained and supervised, and have the chance to develop and improve their skills

Our judgement


People were not cared for by staff who had been supported to deliver care and treatment safely and to an appropriate standard.



Staff had not received appropriate professional development.

We read six staff files to see what training and supervision staff had received. We found that all staff had had recent supervision meetings with the manager. There were training certificates within the staff files but we noted that many of these were out of date.

The manager provided us with a staff training matrix which recorded all staff training and renewal dates. This showed that the majority of staff had received health and safety and moving and handling training. In addition, most staff were trained in dementia care and basic fire awareness.

We found that staff had not received any training, however, about identifying skin wounds and pressure areas and using risk-measurement tools effectively.We spoke with staff to find out how much knowledge they had in this area but found that there was a lack of understanding about identifying pressure damage and the appropriate use of scoring tools to highlight risks to people's skin integrity.

We also noted that none of the staff had received training in handling challenging behaviour. During our inspection we were told about two people who sometimes showed this type of behaviour but staff had not been appropriately equipped to manage this. The training matrix illustrated that training had lapsed for all staff in the following areas; First aid at work, Nutrition, Food safety and hygiene, and Communication. A minimal number of staff had current training in infection control and medication.This showed that staff had not received adequate or current training to enable them to deliver care appropriately and safely to the people using the service.




The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care

Our judgement


The provider did not have an effective system to identify, assess and manage risks to the health, safety and welfare or people using the service and others.



The provider did not have an effective system to identify, assess and manage risks to the health, safety and welfare or people using the service and others.

We saw that there was a 'Comments and suggestions' box in the foyer at the service. In addition, people and their relatives had been asked to complete an annual survey. We read that one person had raised an issue about toilet facilities which had been followed up by the manager. Some of the comments in the last survey which was conducted in November 2012 were:' Very happy with the care' and ' Excellent care Mum is receiving'.

We read records of staff suggestions that new furniture would improve the service. Staff had also requested lockers for their own personal effects. There was no evidence that these views had been taken into account by the provider. We noted a number of pieces of broken or worn furniture during a tour of the premises and saw that staffs' belongings werestored behind a sofa in the green sitting room. This room was being used by people duringour visit. Behind the television in the same room, we found a pair of jogging trousers, tied up at the ankles and full of staff clothing and effects. This showed that the provider did not always listen to staff opinions and requests to improve the service.

A number of audits had been regularly undertaken by the manager and included the first aid box, call bell system and water temperature checks. We also read medication audits and fridge and freezer temperature checks. Neither of these audits however, had highlighted the issues with medicines and the lack of temperature records for the medicines fridge found during our inspection. Although we read that the manager carried out a weekly spot check of the environment, there was no evidence that this had led to adequate maintenance work to improve the premises. This showed that audits had been largely ineffective in highlighting problems; and that remedial action had not always happened.


We saw that, although a schedule had been put in place to record staff training, this had not been used as an effective tool to identify lapses and organise training updates. A number of the care plans we read during our inspection had not been reviewed according to the timescales recorded in them. This meant that people had not been protected from the risk of inappropriate or unsafe care as the provider had not operated effective systems to monitor the quality of the service delivered.


Notification of death of a person who uses services Enforcement action taken

Adult social care and independent healthcare services must tell us when somebody dies in their care. NHS services must tell us when somebody dies because they have not been given the right care

Our judgement


The Commission had not been notified, without delay,of the death of a service user.

We have taken enforcement action against this provider. Please see the 'Enforcement action' section within this report.


We looked at incident and accident reports held by the service and noted that the Commission had not been notified about the deaths of three people which had occurred in the service since September 2013. There is a requirement that all expected and unexpected deaths of people using care homes are notified to the Commission without delay.

We spoke with the Registered Manager about the deaths but they appeared to be unclear about their responsibility to report any such events to the Commission.

This section is primarily information for the provider


Enforcement action we have taken to protect the health, safety and welfare of people using this service

Enforcement actions we have taken

The table below shows enforcement action we have taken because the provider was not meeting the essential standards of quality and safety (or parts of the standards) as shown below.

Cancellation of registration

This action has been taken in relation to:

Regulated activity Regulation or section of the Act

Accommodation for persons who require nursing or personal care

Regulation 18 HSCA 2008 (Regulated Activities) Regulations 2010

Consent to care and treatment

How the regulation was not being met:

The provider did not have suitable arrangements in place for obtaining, and acting accordance with, the consent of service users. Regulation 18.






Care and welfare of people who use services


The provider had not taken proper steps to ensure that each service user was protected from the risk of receiving



inappropriate or unsafe care and treatment. Regulation 9 (1)(a)(b)(i)(ii).






Cleanliness and infection control


The provider had not protected service users, staff and others from the risks associated with the spread of infection.Regulation; 12(1)(a)(b)(c)(2)(a)(c)(i)(ii).






Management of medicines


The provider had not protected service users against the risks associated with the unsafe use and management of medicines. Regulation 13.




Accommodation for Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010



persons who require nursing or personal care

Safety and suitability of premises


The provider had not ensured that service users and others were protected against the risks associated with unsafe or unsuitable premises. regulation 15(1)(c).






Supporting workers


The provider did not have suitable arrangements in place to enure that staff were appropriately supported in relation to carrying on the regulated activity. Regulation 23 (1)(a)








The provider had not protected service users against the risks of inappropriate or unsafe care by means of the effective operation of systems designed to regularly assess and monitor the quality of the services provided and identify, assess and manage risks relating to the health, welfare and safety of service users and others.Regulation 10(1)(a)(b) (2) (b)(i)(c)(i)(e).







Regulation 16 CQC (Registration) Regulations 2009

Notification of death of a person who uses services


The registered person had not notified to the Commission, without delay, the death of a service-user. Regulation 16-(1) (a) (3).

For more information about the enforcement action we can take, please see our Enforcement policy on our website.


About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times.

When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it.

Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers.

You can tell us about your experience of this provider on our website.


How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action.We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.


If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.


How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.

Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.


Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.


Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with thetitle and date of publication of the document specified.

Documents

Inspection Report - Care Quality Commission...2014/09/11 · |Inspection Report | Agape House Limited | September 2014 4 Summary of this inspection Why we carried out this inspection