Inspection on 08/08/08 for Compass Cottage

This is the latest available inspection report for this service, carried out on 8th August 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Compass Cottage 21/02/06

Compass Cottage 30/08/05

Compass Cottage 16/03/05

Compass Cottage 12/01/05

Compass Cottage 17/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Compass Cottage 90 Abbs Cross Lane Hornchurch Essex RM12 4XW Lead Inspector Jackie Date Unannounced Inspection 8th August 2008 11:15 Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Compass Cottage Address 90 Abbs Cross Lane Hornchurch Essex RM12 4XW 01708 443086 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) Compass Residential Homes Limited Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 30th May 2006 Date of last inspection Brief Description of the Service: Compass Cottage is a three bedded home for adults with learning disabilities and challenging needs. The owners have two other homes in the area. One is next door to Compass Cottage and the other is a few minutes away in the same road. People tend to spend time in all of the three homes and staff cover in all three homes when needed. At present the home does not have a registered manager and the main responsibility for the management of the service lies with the area manager. The area manager is in the process of applying to be the registered manager. At the time of the visit two men were living in the home. It is in a residential area of Hornchurch close to local shops and amenities and to local transport networks. On the ground floor there is a single bedroom, a toilet and a large open plan kitchen/dining/living area. On the first floor there are two single bedrooms and an office. The building does not have any adaptations for people with physical disabilities and would not be accessible to wheelchair users. The people living at the home are supported in community-based activities by the staff team. The scale of charges per week for each person range from £800 to £1600 per week. This information was taken from the Statement of Purpose. Information about the service provided is contained in the service users guide. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was unannounced and started at 11:15 am. It took place over six hours. This was a key inspection and all of the key inspection standards were tested. Staff were asked about the care that people using the service receive, and were also observed carrying out their duties. People using the service were asked to give their views on the service and their experience of living in the home. All of the shared areas and two bedrooms were seen. Staff, care and other records were checked. Relatives, social workers and healthcare professionals were contacted and asked for their opinions of the service. At the time of writing this report no feedback had been received. Services are now required to complete an AQAA (Annual Quality Assurance Assessment) and the completed form was received in July 2008. Information provided in this document also formed part of the overall inspection The inspector would like to thank the people living at Compass Cottage and staff for their input during the inspection. What the service does well: What has improved since the last inspection? Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 6 The 4 requirements from the last inspection have all been met. The lounge was redecorated and new flooring fitted. One person was supported to move out of the home and back to live with her family. A new person was supported to move into the home and has settled in very well. He said that he was happy there. There has been a stable staff team and people are supported by staff that they know and who know them. 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. The summary of this inspection report can be made available in other formats on request. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 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 Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 5. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Appropriate information is gathered on people before they move into the home and this gives staff a picture of the individual’s needs and how to meet these. People thinking of moving into Compass Cottage and their relatives can spend time in the home to find out what it would be like to live there and to enable them to make a choice about living in the home, within their capacity to do so. People have contracts and therefore have information about the service that they are entitled to. EVIDENCE: One of the people living at home moved in last year and the file of this person was examined. It contained the assessment by the placing authority and an assessment by the then manager of the home. There were also additional reports from an occupational therapist and a speech and language therapist. The care plan was in place and was reviewed monthly during the first six months that the person lived at Compass Cottage. Therefore sufficient information was gathered on that person to enable their needs to be identified and for a decision to be made about the home’s capacity to meet their Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 9 assessed needs. There was also evidence that the person visited the home on occasions and had met the other people living there. Therefore, when possible, people are given the opportunity to visit the service and to meet staff and other people living there before they decide if they want to live there. People have individual contracts between themselves and the provider. The contracts were available at the home and copies were seen in peoples’ files. Therefore they have details about the service that they are entitled to. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Peoples’ care plans and risk assessments contain sufficient information to enable staff to safely meet their needs. People are consulted about what happens in the home. EVIDENCE: Each person has a plan which gives details of how they need/like to be supported. Areas covered included education, vocational, leisure, spiritual, and cultural need. Both care plans were examined during the visit and information contained in them was appropriate and relevant. They also indicate what individuals like and dislike. For example one person’s care plan states that he likes the shops, the cinema, Chelsea and the zoo. Care plans seen were up to date and had been appropriately reviewed with the person, and when appropriate their relatives and representatives. As stated previously the care plan for one person was reviewed each month for the first six months that he lived there and was updated as he settled in and staff got to know him better. Behavioural guidelines are in place and there is also guidance on how Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 11 to communicate with each person. Therefore plans contain appropriate and current information so that staff can meet peoples needs. Daily recordings are made about what each person has done and support that they have been given. These recordings tend to be quite general and a bit limited. This is an area for ongoing development and the manager is aware of this. Therefore there is information about each individual, which can be used as part of the review process and to identify ongoing and changing needs. Improving the quality of this information will assist this process. Risk management strategies are in place and these identify and indicate ways in which the risks can be reduced to enable peoples’ needs to be met as safely as possible. These had been reviewed and were up-to-date. They include updated guidelines for managing behaviour. Therefore staff have up-to-date information about risks and how to minimise them. This will help to keep everyone safe. Both of the people living at Compass Cottage can and do express their views about what they want to do and what they like and are involved in the running of the home as far as they are able. They are encouraged to make decisions about what happens as far as they are able. Staff said: “they choose what they want to do, when to get up and when to go to bed. If they say no they mean no.” Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. People are encouraged to take part in activities and to be part of the local community and have an active social life People are supported to keep in contact with their relatives. People are supported and encouraged to have a diet that is healthy and meets their needs. EVIDENCE: Both of the people living at Compass Cottage are able to say what they want and what they like to do. At present two staff are on duty for each shift and therefore people living at the home can receive the support they need to do individual activities. As stated previously one person likes to go to the shops, to the cinema and is very fond of animals. He also likes to go to the pub for a drink and chooses which pub he wants to go to. The other person likes to eat Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 13 out and often has lunch in Hornchurch. Both people go to healthy living club on Wednesdays and this includes members of the general public. They get advice on healthy eating and also do activities such as line dancing and salsa. They both said they enjoyed going to this and also that they enjoyed the film Mama Mia. They go to a Tuesday club and a Saturday night disco but neither person is a regular churchgoer. One of the people living there had just returned from a short trip and had stayed at youth hostel. He said that he had enjoyed this and was going to have some more trips away and stay at different hostels. They are planning a holiday at Hemsby and are hoping in the future to go to Euro Disney and are in the process of getting passports to facilitate this. Another person does voluntary gardening work at a local church. Feedback from staff was that the people living at Compass Cottage go out often. Both people using the service have contact with their families, although this is limited. One of the men had recently had a birthday and told us about his party and also about going out for a meal with his relatives. A recent relative survey confirmed that both families were happy with the service provided. People are encouraged and supported to be as independent as possible and to do things for themselves. One person made tea for himself and for the inspector and later made a drink for the other person living at the home. He also told us about the things that he cooks. Care plans include ways in which people are encouraged to be independent. For example, encourage and prompt him with his personal care, encourage him to do weekly chores and to change his bedding. As previously stated both men are able to say what they want and what they like and are therefore able to say what they want to eat. One person, on the advice of the speech and language therapist, needs to have a soft diet with sauces and gravy and the staff team support him to have this. Again as previously stated the two men do attend a healthy living club and get advice and guidance on healthy eating there. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. People using the service receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. People are given their regular prescribed medication safely but medication records need to be more robust to minimise the risk of errors and to provide a more accurate record of medication administration. EVIDENCE: Both people using the service are fairly independent with their personal care and require reminders, prompts and minimal supervision. They are supported by staff that know them well. The staff provide the support that people need to maintain a good level of personal hygiene and also to maintain their independence. Both people using the service go to the local doctor and specialist help is received from the community learning disabilities team. There are close links Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 15 with the psychiatrist and the community nurse. There was also evidence of input from a speech & language therapist and the dietician. Staff support people to all of their medical appointments. People have had checks from the optician, dentist and when appropriate chiropodist. ‘Health action plans’ are in place and records are kept of appointments and outcomes. As previously stated people have joined a healthy living club and are encouraged to keep themselves as well as possible. One person had been experiencing a lot of difficulties due to some medication issues. This has now been resolved and with good support from the staff he is now more settled. There have been instances when people living at Compass Cottage have been taken ill and staff have taken prompt action and called the emergency services. Therefore people are well looked after in terms of their healthcare needs. Neither of the people living in the home are able to self medicate and staff administer medication. The manager trains staff to administer medication using a training pack & DVD. Staff have to complete a questionnaire and are monitored and observed. They also do an in house test. They cannot administer medication until they have been deemed competent. Medication is securely stored in a locked cabinet in the office and most medication is in a monitored dosage system. In line with good practice the medication file has photographs of people that take medication and details of any allergies. Medication administration records are kept and are up-to-date. People taking medication have had medication reviews. This is also good practice. Examination of the MAR (Medication Administration Record) found that these had been appropriately completed. Guidelines/protocols are in place for the administration of some PRN (when required) medication to assist staff as to when and how to administer this medication. However these need to be in place for all such medication. This will ensure that staff are clear about the administration of this medication and it will also lessen the risk of error. There were some handwritten entries on the MAR (Medication Administration Record) charts but these were not signed or dated. For accountability any handwritten entries by staff require endorsement with date and signed initials or signature. It is recommended that the medication file also contains a list of staff that are able to administer medication and a sample of their initials. This is good practice and helps to easily identify who has been responsible for the administration of medication and when. In the office there is a copy of a BNF (British National Formulary) book that gives information about medication. This was dated March 2006. It is recommended that an up-to-date edition be purchased to ensure that staff have access to the latest information. All of this will help to ensure that people receive their prescribed medication as safely as possible. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. There is a complaints procedure that is followed in the event of any complaints being made. Staff have received safeguarding adults training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. Appropriate action was been taken when a safeguarding issue occurred. This gives people a greater protection from abuse. EVIDENCE: There is a complaints procedure, which is displayed in the home. Both people living at Compass Cottage are able to say if they are not happy about anything and one of them has access to an independent advocate. There was one recorded complaint and this had been appropriately dealt with. The service has a safeguarding adults policy and procedure and staff have received safeguarding training. This forms part of the induction, part of NVQ training and the proprietor also provides refresher training. Staff were aware of safeguarding issues and their responsibilities to those using the service. A safeguarding issue arose earlier this year as a result of a spell of aggressive behaviour from one of the people using the service. This was reported and appropriately dealt with. Both parties were supported as a result of the incident and the situation has now been resolved. Staff spoken to said that Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 17 they did not have any concerns about the care of people living at Compass Cottage and felt that they received good care. The local authority acts as appointee to one of the people living at Compass Cottage and he visits their office each week to collect his cash. The other person goes to a local building society with staff and he signs to collect his own cash. For each person a small amount of day-to-day cash is kept in a tin in the office at the home. The remainder of their cash and any documents are stored in the safe of the managers office and are only accessible by the manager. Appropriate records are kept and receipts are obtained as far as possible. Cash held is checked each hand over. The cash held for both people was checked and found to be correct. Systems are in place to ensure the peoples money is safeguarded. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30. People using the service experience adequate quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. People using the service live in a home that is suitable for their need in terms of its size and location. However some areas are in need of some repair and refurbishment so that it is a comfortable environment for them to live in. EVIDENCE: The home is in a residential area of Hornchurch close to local shops and amenities and to local transport networks. On the ground floor there is a single bedroom, a toilet and a large open plan kitchen/dining/living area. On the first floor there are two single bedrooms and an office. The building does not have any adaptations for people with physical disabilities and would not be accessible to wheelchair users. Neither of the people living there require any aids or adaptations. We saw all of the communal areas and both people living there showed us their bedrooms. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 19 Since the last inspection the lounge/dining area has been redecorated and new flooring fitted. However due to problems with the gutter there are damp patches and this area needs to be decorated again. In the hall there are a lot of marks on the wall and this area needs cleaning and if this is not successful redecorating. The paintwork also needs cleaning. On the first floor has a bathroom with a toilet. However on the day of this inspection there was a broken toilet seat and there was no soap or towels. This was pointed out to the manager and soap and towels were provided. The broken toilet seat must be prepared or replaced and systems must be in place to ensure the only breakages all required repairs are reported and actioned. It must also be a system to ensure that necessary items such as soap and towels are readily available all times. One of the bedrooms had been personalised by the person living there. Hes a Liverpool fan and there were lots of flags, banners and other personal possessions. However the other bedroom was in a poor state of repair with items of broken furniture. This bedroom needs to be redecorated and furniture either repaired or replaced. There is a garden at the rear of the building and people living the home do use this. It had been an attempt to grow some vegetables in the garden this has not been successful in the garden now does need some attention. Meeting the above requirements will ensure that people live in a clean, hygienic and comfortable home that meets minimum requirements for the environment. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Staff have the opportunity individually and collectively to discuss their own development or any problems and developments within the service and feel supported by the manager. Staff are receiving the necessary training to give them the skills to meet peoples’ current needs and provide an appropriate service for them. Staffing levels are sufficient to allow for this. People using the service are supported and protected by the organisations recruitment practice. EVIDENCE: Two staff are on duty during both day and night shifts. This is due to the fact that at present one person has one to one support from staff. As there are only two people living at Compass Cottage the reality is that they both have individual support and can therefore choose what they want to do and be supported to do this. From observations during the inspection, examination of Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 21 the rota and discussions with staff it was evident that there were sufficient staff on duty to meet people’s needs. The service operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. A random sample of three staff records were checked. The files contained copies of the application form, interview questions and interview assessments. There was also evidence that the necessary checks had been carried out. This includes references, identification, POVA (Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) checks. Therefore the recruitment procedure offers safeguards to people using the service. From discussions with staff and looking at records it was apparent that the appropriate training is being provided to staff. All staff have had induction training and other training has included protection of vulnerable adults, medication, communication, food hygiene, fire safety, makaton and epilepsy. Of the 12 permanent staff working in the Compass services 8 have achieved NVQ level 2 or above and 3 are working towards this. Therefore the staff team are being provided with the training and skills that they need to meet the needs of the people using the service. Staff meetings are now being held monthly. Staff spoken to said that they do receive supervision but that recently this had been “every so often”. The main reason for this had been the changes in management arrangements. The new manager has started supervising staff herself with a view to senior staff doing this in the future. This gives staff collectively and individually an opportunity to discuss concerns, the care of people using the service and the development of the service. There was evidence on file that staff have had annual appraisals and that training and development needs have been identified. Staff spoken to said that they get good support and that the manager understands and is really helpful. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. People living at Compass Cottage benefit from a service that is appropriately managed and where their views and opinions are sought and acted upon as far as is possible. People live a safe home but systems need to be in place to ensure that all statutory checks are carried out within the specified time frame. EVIDENCE: Since the last inspection there has been two changes in management. The new manager is also the area manager and she will be the registered manager for Compass Cottage and also Compass Lodge. She will oversee Compass Grove. She has a NVQ qualification and has obtained the RMA (Registered Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 23 Managers Award) and has also worked in the Compass homes for many years. The manager is now in the process of doing a skills for leadership in care course. She is aware of areas that need to be developed and improved and has started to work towards this. The manager has the necessary skills and experience to manage this service. Feedback from staff was that the manager was supportive, helpful and approachable. The manager has not yet made an application to be registered with the Commission. In line with procedure she has completed all of the necessary paperwork and has obtained the information and all but one of the checks required. As soon as her CRB (Criminal Records Bureau) is received she will be able to submit the application to the Commission. The staff team carries all of the necessary health and safety checks out regularly. For example fire call points are tested weekly, as are hot water temperatures. Appropriate servicing is carried out on the fire system and fire equipment. Portable appliances have been checked recently and items that were not satisfactory are being replaced. The electrical intake was tested as safe last year but the gas safety certificate expired in February 2008. This must be renewed each year. A satisfactory Gas Safety certificate must be obtained to confirm that gas appliances and systems are safe. The quality of the service provided to people using the service is monitored by the manager and by the proprietor. For example the manager has recently completed night spot checks and surveys have been sent to relatives to get feedback from them. Monthly monitoring visits were carried out by one of the proprietors to assess how effectively the home is operating to meet its stated aims and objectives, and reports were written. These indicate the action to be taken when deficiencies are identified. However this proprietor has been unable to carry out these visits for a while and the last recorded visit and report on file was in November 2007. The manager did say that another proprietor visits regularly and that there is very regular contact with the proprietors. The registered provider must visit the home unannounced at least once a month to monitor the service provided. They must then prepare a written report on the conduct of the care home. It is important that the formal monthly monitoring visits are carried out regularly so that the service is robustly monitored. Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 2 X Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 25 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. Standard YA20 Regulation 13 Requirement Protocols/guidelines must be in place for any PRN (as required) medication. Staff will then be clear as to when, how and why to administer this medication. For accountability any handwritten entries made by staff on MAR (Medication Administration Record) charts require endorsement with the date and signed initials or signature. The lounge needs to be redecorated so that people live in a homely and comfortable environment All parts of the home must be kept clean so that people live in the clean and hygienic environment. The walls in the hall need to be cleaned and if necessary redecorated so that people live in a clean, comfortable and homely environment The bedroom occupied by the newest resident needs to be redecorated and broken furniture needs to be repaired or replaced so that he lives in a comfortable DS0000027839.V369244.R01.S.doc Timescale for action 30/09/08 2. YA20 13 31/08/08 3. YA24 23 31/03/09 4. YA30 16 30/09/08 5. YA24 23 31/03/09 6. YA26 23 31/12/08 Compass Cottage Version 5.2 Page 26 and safe environment. 7. YA24 23 A system needs to be in place to 30/09/08 ensure that any repairs are breakages are reported and dealt with as soon as possible. This helps to keep people living there safe. A system needs to be in place to 30/09/08 ensure that all areas of the home are kept clean and hygienic. This helps to protect people living there. The registered provider must 31/12/08 visit the home unannounced at least once a month to monitor the service provided. They must then prepare a written report on the conduct of the care home. This is so that the service is robustly monitored. A satisfactory Gas Safety certificate must be obtained to confirm that gas appliances and systems are safe. 30/09/08 8. YA30 16 9. YA39 26 10. YA42 13 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 YA20 Good Practice Recommendations It is recommended that the medication file contains a list of staff that are able to administer medication and a sample of their initials. This is good practice and helps to easily identify who has been responsible for the administration of medication and when. It is recommended that an up to date copy of the BNF (British National Formulary) book be purchased to ensure that staff have access to the latest information. 2. YA20 Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Compass Cottage DS0000027839.V369244.R01.S.doc Version 5.2 Page 28 - 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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