Inspection on 21/02/06 for Compass Cottage

This inspection was carried out on 21st February 2006.

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

The inspector 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Compass Cottage 30/05/06

Compass Cottage 30/08/05

Compass Cottage 16/03/05

Compass Cottage 12/01/05

Compass Cottage 17/03/04

Similar services:

Ashlong House

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Edenvale

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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 08/07/2008.

CARE HOME ADULTS 18-65 Compass Cottage 90 Abbs Cross Lane Hornchurch Essex RM12 4XW Lead Inspector Mr Roger Farrell Unannounced Inspection 21st February 2006 02:00 Compass Cottage DS0000027839.V284298.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 Compass Cottage DS0000027839.V284298.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. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 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 Ms Joanna Martine Smith Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: Compass Cottage a registered private care home that accommodates and supports up to three people who have learning disabilities. It has been operating for ten years, with the two of the current residents having moved-in in when it opened. The owners have two other homes in the area, one of which is next door. All residents have single bedrooms, and share the homely ground floor open- plan kitchen/lounge. Historically one manager has been responsible for this house and Compass Lodge, a short walk away further along Abbs Cross Lane in Hornchurch, and this remains the case. She is normally based at Compass Lodge. These two homes are inspected separately, though some paperwork covers both settings, such as staff files. Good standards of cleanliness and home-making are maintained, and this is a consistent finding at unannounced visits. The home is less than a mile from the shops and other facilities of Hornchurch town centre. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 4.15 and 5.30pm on Tuesday 26 February 2006. All three homes in this group were visited on the same day. Jo Smith, the registered manager for Compass Cottage and Compass Lodge was available throughout the day. She took the lead in dealing with the enquiries about Compass Cottage. Some of the areas that apply to both homes, such as staffing, were checked at Compass Lodge earlier in the day. The last inspection of this home on 30 August 2005 was also unannounced. At that time most of the core standards were covered. A copy of that report is available at the home, and can be found on www.csci.org.uk. That report says the overall findings were the most positive found since the new rules covering care homes were introduced nearly four years ago. One person who had worked at the home for three years had become an ‘assistant deputy manager’, and this had helped with the day-to-day coordination. This included improved up-to-date records being available, such as better service user files and safety records. However, soon after that visit this person suffered a period of ill health, and had just started to return gradually to duties six months on. In the meantime, another person has taken a more senior lead, but she was soon due to commence maternity leave. This visit concentrated on looking at staff team continuity, progress with the two requirements from the last visit, and an update on how residents spend their time. Two residents have lived at this home since it opened in June 1996. A person who joined this group in December 1999 had moved out a week before this visit. She had transferred to the two-place home next door. This was partly because she is a friend of the person who lives in Compass Grove, but also because some tensions had arisen due to noises – the two remaining residents saying they like a quiet household. What the service does well: This cottage style terraced house is set just back from the main Abbs Cross Road. The overall level of maintenance and décor is quite good. The shops, transport links and other facilities of central Hornchurch are in walking distance. At this visit the home was again found to be comfortable, safe, and clean. There is a good-sized garden with seating, that backs on to a brook and parkland. The service users whose home this is have good living and social skills. This means that they lead relatively independent lifestyles and can make choices about how they spend their time, both within the house and outside. The descriptions of how each person is helped with their regular activities shows a good balance between individual freedoms and knowing where some help is Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 6 needed. At this visit only one resident was at home, the other person being away staying with her family. What has improved since the last inspection? 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. Compass Cottage DS0000027839.V284298.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 Compass Cottage DS0000027839.V284298.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): 2 and 5. The inspector has seen the assessment documentation ready to be used in future. This includes the NCHA’s standardised ‘application form’ and the ‘assessment schedule’. EVIDENCE: This group of three homes generally provide a ‘home for life’, so vacancies are very rare. However, last year the inspector raised major concerns about the poor planning around an attempt to quickly move a new resident into the home next door. He asked for a much clearer policy and procedure on assessment and move-ins, including clarifying the central decision-making responsibility of the registered manager. He has been shown a series of documents that will be used as the framework in the future. These include a ‘pre-service and needs assessment’; ‘trial periods’; ‘admission procedure’; and ‘move-in checklists’ adopted from the ‘Mulberry’ series – as well as the NCHA forms mentioned above. These set out a responsible approach to introducing prospective resident in line with the requirements set out in this group of standardised. At the last visit to this home the assessment standard was rated as met as it accepted that the company would use these guideline if a vacancy occurred. Part of the agreement covering the transfer of a resident to the neighbouring home is that her place at this home will be held for three months to make sure she settles. This shows a responsible approach. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 9 Nevertheless, the inspector stressed the need to follow the company’s revised framework when the time comes to consider introducing a new person into Compass Cottage. A major consideration will be compatibility with the two established residents. The manager said the homes do not accept emergency admissions. There are contracts covering each person’s terms of residency on their main files. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0. These standards are covered in the last report. The two residents are well established in this home, and continue to show high levels of independence. They live active lives, and the help given by staff is well judged in ensuring that the residents follow their chosen lifestyles, which includes being out a lot. EVIDENCE: The last report spoke positively about the introduction of the ‘Person Centred Planning’ files. Progress with these will be checked at a subsequent visit. Compass Cottage DS0000027839.V284298.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 are given good guidance and support to take part in work, educational and social activities, including holiday breaks. This includes maintaining regular contact with their families. There are records covering social activities. EVIDENCE: A feature of this household is that service users have strong independence skills and lead busy lives. In some limited instances prompting and guidance is necessary, but in general they are confident and competent in their social abilities. The two residents are able to exercise choice about what activities they take part in. This includes having close links with members of their family. One resident has an ambition to move in with her family in the future. The residents can use keys to the front door and their bedrooms. There are no restrictions other than keeping staff informed of matters such as return times. On the day of this visit one resident had arranged to go shopping with a staff member. He later told the inspector that he had been successful in buying the two cd’s he set out to find. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 12 There are up-to-date daily planners listing the main activities. There are also yearly resumes of main social events, such as holiday breaks. One person attends a yoga class, but that is the only attendance at organised centres or colleges at present. There is an intention to reintroduce literacy sessions. In general each resident prepares their own meals with some assistance from staff. There are daily menu sheets recording what each person has had to eat, covering breakfast, lunch and the evening meal. All residents at times assist with the main weekly shop. The kitchen has a good range and variety of foodstuffs, including fresh vegetables and fruit. Residents tell the inspector that they are satisfied with the catering arrangements. Compass Cottage DS0000027839.V284298.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): 0. These standards are covered in the last report. This home is good at supporting residents with their health care needs, and is now keeping better records of contacts with doctors, dentists, opticians and so on. Better guidance is also available on medication. EVIDENCE: Assistance with personal care is largely limited to giving prompts. The careplan files have a ‘my medical details’ section, with good tracking sheets for contacts with doctors and other health care workers. Attendance at medical appointments is one area where it is necessary to accompany residents, both to help relieve anxiety and ensure understanding of information or instructions. The GP is described as helpful, with a good attitude towards listening to residents. The arrangements for storing and recording medication are satisfactory. Medication is provided by a local pharmacist in blister packs, with printed administration sheets. This pharmacy also provides training sessions, and all staff have to complete a competency test before being responsible for giving drugs. The medication administration files have individual profiles, and instructions to follow if an error occurs, though there have been no reported errors during the last year. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 14 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. The manager is aware of the expectations about recording, reporting and following through on complaints and any allegations of abuse. The necessary range of guidance is available. At this visit the manager was able to describe a more thorough approach to following through complaints. EVIDENCE: The manager gave the inspector an update on a matter dealt with through their protection procedures. A staff member had not followed the expected procedures when applying for store cards for residents. The matter was reported to the police, but no fraud was found to have taken place. The staff member was suspended and referred to the temporary POVA list. The person has not worked at the home since the irregularity was found. The manager explained how a complaint by a service user had been followed through. This demonstrated that concerns are taken seriously. The requirement set in the last report on recording complaints has been achieved. There is available a file containing the required range of policies and guidance covering protection issues and responses. This includes a copy of ‘No Secrets’; the in-house policy and ‘Pavilion Pack’; and the Havering guidelines. All individual staff training profiles seen included confirmation that they have attended a training day on this topic, the last having been the previous month, which was led by one of the owners. Staff who had attended that session completed an evaluation form. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 15 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 and 30. The building is suitable to meet the needs of residents, and has quite a homely appearance. Residents’ rooms show each person’s individual tastes and interests. EVIDENCE: Communal space is an open plan lounge diner, with a countered-off kitchen. All conditions were found to be satisfactory, and residents say they are satisfied with these facilities. All three bedrooms are above the minimum space standard. Each has a good range of home entertainment equipment. The bathroom is on the first floor. This has a basic decorative appearance, but was found to be clean and functional. The washing machine and dryer are in the small room used as the office on the first floor. This is said not to be problematic, and the inspector was told that this arrangement has previously been seen and approved by a fire safety inspector. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 16 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): 32, 34, and 35. Last year’s inspection reports said that the main problem was keeping staff. The main positive finding at this visit was that staff retention has improved considerably. EVIDENCE: There is an overlap between the staff that work in this home and at Compass Lodge. The staffing complement for Compass Lodge and Compass Cottage combined is – manager; full-time deputy; 2 full-time assistant deputy managers; 1 full-time senior care assistant; and 5 full-time and 5 part-time care assistants, of which 4 cover night shifts. Cover in this house is 1 staff member on duty on the early and late shifts (7.30am to 10.00pm). Night cover is one waking person. At present this means a ratio of one staff member to two residents through the day. Current rotas show occasional ‘long-shifts’, though these were said to be voluntary, and are followed by a day off. The good news was that no staff have left since the last inspection, other than one person being dismissed. Fifty per cent of staff have been with the company for over a year, with nearly all others having started in early summer last year. This compares very favourably with the position reported earlier last year. At that time the manager’s main frustration was that the time being spent on early stage induction and subsequent training was largely being lost. The Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 17 owners were asked to examine the issue of staff turn-over, but the subsequent report said their brief response sidestepped this issue, saying nothing worthwhile about how this problem was to be addressed. Nevertheless, the current profile is much better. This improved stability means that the manager can proceed with a more planned strategy for training. The training profiles for the longer serving staff show that they have covered the main core areas such as food hygiene, fire safety, medication, first aid, and manual handling. The inspector saw examples of recent training needs assessments done in supervision. However, the expectation is that care homes should by now have reached the target of 50 of staff with a relevant qualification. Details provided by manger show that only two staff have an NVQ at Level 2 or 3, with four currently on such a training scheme. One further person was due to start. Reasonably regular staff meetings are occurring, and these are now for staff from all three of the company’s homes. The manager explained how an ‘Employee of the Month’ scheme was working. The manager is good at carrying out the required range of vetting - such as getting two references, a CRB certificate, and checking permission to work. The well arranged staff files have a training profile, induction checklist and copies of course certificates. This reflects the positive steps that have been taken over the last couple of years to have records that meet the standards. The manager is now aware of the ‘PovaFirst’ fast checks. At this visit there was one outstanding CRB check, an application having been submitted last September. This person was not working at this home as it involves ‘singlehanded’ shifts. Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 18 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 and 39. There is generally adequate evidence to support the standards tested under this heading. The manager visits this house a couple of times a week and has regular contact with the service users as they pop-in to the Lodge regularly. Having assistant deputy managers in this home has helped ensure better records. EVIDENCE: The manager has fifteen years experience in the care sector, eight of these in a management position. She commenced with this company in January 2001, managing the smallest of the group of three homes. She took on manager responsibilities for Compass Lodge and Compass Cottage in January 2003. Her title is now ‘Area manager’ as she supervises the manager of Compass Grove. She has got the NVQ level 3 award. She is due to complete the RMA Award in July 2006. The owners and manager do carry out spot-checks, including at nights, and take action where they find deficiencies. It was one of the owners who spotted Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 19 the financial irregularity last October that led to the protection investigation. The owners use a tick and comment ‘monthly report’ format produced by the NCHA, and have done brief business plans. At announced inspections the owners have made available information from their accountants confirming the viability of the business. At his last visit the inspector asked to see a range of records and certificates covering health and safety. This included tests of the battery alarms and the monthly fire drills; contractor tests of the extinguishers; electrical and gas certificates; and information on Coshh materials. These were all satisfactory. Reports of the last visits by a fire safety inspector and environmental health said conditions were fine. An independent infection control and hygiene audit gave the home a commendable overall score of 93 . Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 20 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 X 4 X 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 3 X X X X Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes – one item is carried forward. 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 YA32 Regulation 18 Requirement Ensure that all staff have sufficient training in the core areas, and that there is a plan working towards the target of 50 of staff holding a recognised qualification. Timescale for action 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Compass Cottage DS0000027839.V284298.R01.S.doc Version 5.1 Page 23 - 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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