Inspection on 21/02/06 for Compass Grove

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 Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Compass Grove 09/05/06

Compass Grove 30/08/05

Compass Grove 23/03/05

Compass Grove 18/01/05

Compass Grove 17/03/04

Compass Grove 07/01/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Compass Grove 92 Abbs Cross Lane Hornchurch Essex RM12 4XW Lead Inspector Mr Roger Farrell Unannounced Inspection 21st February 2006 2.15pm Compass Grove DS0000027840.V284301.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 Grove DS0000027840.V284301.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 Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Compass Grove Address 92 Abbs Cross Lane Hornchurch Essex RM12 4XW 01708 475915 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 Christine Jean Mitrovic Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Compass Grove DS0000027840.V284301.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 Grove is registered to provide accommodation and support to two people who have a learning disability. This small terraced cottage has a delightful contemporary interior, with good attention to comfort and homemaking. Next door is Compass Cottage, a three-place care home operated by the same owners, but they are registered as separate services and have different managers. There is a third home in this group further along Abbs Cross Road called Compass Lodge. Compass Grove opened in June 2001, and for nearly all of the period since there was only one resident. In February 2006 a residents from Compass Cottage moved next door to Compass Grove, both residents having been friends over many years. Compass Grove DS0000027840.V284301.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 2.15 and 4.15pm on Tuesday 21 February 2006. The other two homes in this group of three also had visits on the same day. The registered manager of Compass Grove, Christine Mitrovic was on duty. The manager for the other two homes, Jo Smith, supervises her. Jo Smith arrived at Compass Grove after an hour to support Christine Mitrovic. Some broader checks were carried out at Compass Lodge earlier in the day. The last inspection of Compass Grove on 30 August 2005 was also an unannounced visit. Most of the core standards were checked at that time. The report of that visit is available at the home, and can be seen at www.csci.org.uk. The two main areas checked at this recent visit were progress with the requirements set in the last report, and how the recent move-in had been planned. This report concentrates on these two themes. With the exception of a three-month period in 2003, the established resident had not shared this home since she moved in June 2001. Last year’s main inspection report was highly critical of a failed attempt to introduce a second person in October 2004, highlighting a series of poor decisions and bad planning. Assurances were received that future assessments and move-in arrangements would be carried out in line with the company’s revised policy and procedure on new referrals. A resident who had lived next door for six years moved into Compass Grove a week before this visit. The inspector spoke with both residents together and separately, and they each said that they were very happy with the change. All the indications about this new house-sharing arrangement were positive at this early stage. This included the better steps taken to plan the transfer, and confirm the agreement of the two service users. One said – “I am very happy with how things have gone. I was asking to move here for quite a long time. I am now with my mate. I know all the staff and they were used to me as I came here most days. Chris (one of the owners) helped me move my things and most things are now sorted.” The other resident commented – “I am pleased that she has moved in. She is my friend. It will work out well…such as using the kitchen. I have told you in the past that I wanted company.” Staff cover in all three homes was in line with the rotas and expected level of cover. Afternoon staff arrived on time for their shifts, and there was good coordination between the homes to make sure residents going out were escorted whilst other residents visited neighbouring houses. What the service does well: Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 6 This cottage style terraced house is set just back from the main road. The overall level of maintenance and décor is 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 goodsized garden that backs on to a brook and parkland. This comfortable house continues to provide the residents with a homely and good quality standard of accommodation. There is a good tradition of helping the established resident have a settled home life, and good support for her busy lifestyle using community facilities. Her new housemate also has strong independence skills, and a wide range of activity away from the home including doing a part-time job for a charity and helping others use Makaton signs. What has improved since the last inspection? What they could do better: All the signs were that the new arrangement was going well, with both residents seeing it as a positive development. The uncertainty of filling the long-standing vacancy has been considerably reduced as both service users have had a friendship over a long time. The manager is nevertheless sensitive as the established resident has had ‘the home to herself’ over such a long period, though she has consistently said that she wanted a housemate. Supporting two people with the same level of staff cover will need to be monitored. For instance, the manager covers regular dayshifts, meaning that contact with staff has mainly been at handovers rather than there being separate supervisory time. This will need to be reviewed in the course of the year. The number of requirements has reduced considerably over the last year. The manager has moved gradually towards taking fuller responsibility. She has had the support of the more senior manager based at Compass Lodge. The owners have given undertakings that they will assist Christine Mitrovic develop her managerial skills. At this recent visit she showed better knowledge of documentation, but still deferred to others on some points. For instances, she had difficulty locating the last inspection report, and the ‘action plan’ response Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 7 returned in her name. It needs to be a matter of discussion with the owners why it has been necessary to again carry forward requirements, albeit a reducing number compare to previous reports. This manager still needs a support framework to help her to further develop ‘stand-alone’ manager competencies. 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 Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 8 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 Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 9 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, 3 and 4. The arrangements covering the move-in of the resident from the neighbouring house were satisfactory. EVIDENCE: As stated above, the inspector had asked for guarantees that any future move in would involve considerably better planning because of the failures that occurred last time a new person was introduced. The commitments included the manager rather than the owners taking a lead in the arrangements. The circumstances this time are very different as the two residents had been neighbours and friends for six years. Both are assertive, and are able to say what are their choices. The person transferring and staff in her new home know each other well as she would ‘visit most days. Discussions took place with each service users’ care managers, lead community nurses, and families ahead of the move. A pre-move-in review was held for the person who was transferring, involving all key staff and a family representative. There had also been a recent psychiatric consultation. Helpfully, part of the agreement is that the place at Compass Cottage will be held open for three months to be extra sure that the new house-sharing arrangement works out. Minutes of the main transfer review meeting had not yet been typed-up. But based on the details given by the manager, and the comments of the two service users, the requirement on this matter has been recorded as achieved. Compass Grove DS0000027840.V284301.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 were covered at the last visit, the report saying – “This home continues to provide a good framework of support for the service user. This includes recognising her strong independence skills, whilst having support in more vulnerable areas, such as going out. This home has a good tradition of having suitable practice notes, and this is still evident…. The service user’s file is being kept up-to-date, and is well arranged. This included a front index sheet, detailed up-dated care-plans; a CPA review, and a range of monitoring forms.” EVIDENCE: Please refer to the comment under Standard 19 about keeping accurate medical tracking sheets. The new resident’s file had been transferred from the neighbouring house when she moved across a week earlier. Other than day-to-day entries, no other changes had yet been made. At the next visit the inspector will check how the care plan and other elements such as risk assessments have been updated to reflect this person’s changed circumstances. Compass Grove DS0000027840.V284301.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. Both residents live active lifestyles and are involved in a range of varied activities throughout the week. This involves staff escorting the two service users when travelling to their work places, clubs and social events. Both individuals’ level of independence means that they are involved in doing their shopping and preparing their own meals. Both said that they are happy with how their shared use of the kitchen is working out. EVIDENCE: Both service users live active lifestyles. There is an up-to-date programme showing each person’s regular planned activities. Both have attended a range of college courses over recent years and shown the inspector their certificates. One resident does a part-time job in a charity shop a couple of days a week. The other person was due to start working in a café. Both attend evening clubs two or three times a week, and a fortnightly disco. Also, both have regular contact with their families. Both attend ‘keep-fit’ sessions, and a ‘women’s group. As stated above, a priority for this service is to make sure that both continue to have the required level of support to continue their busy lifestyles. Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 12 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. The requirement to keep accurate medical contact sheets is carried forward again as an error was found. The manager had been told to monitor the safe administration of medication. This involved making sure recommendations made in pharmacy reports are maintained. At this recent visit the inspector was told that there had been no recent errors, and all staff have received training in this important area. EVIDENCE: Service user files do have separate contact sheets for each type of practitioner such as the GP, dentist and optician. However, errors are still happening, such as entering details of a recent psychiatric consultation on the page used for blood tests. It was again stressed that the manager must make sure that these records are accurate. The requirement covering medical contact sheets is therefore carried forward again. Last year’s reports talked about the need to improve medication arrangements. A report in January 2005 listed a range of concerns about safety with medication. The registered persons were served with an ‘Immediate Requirement Notice’ for a failure to comply with Regulation 13(2) and 18(1)(c)(i) of the “Care Home Regulations 2001”. Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 13 Improvements were found at subsequent visits. This included better information in the medication administration file explaining the purpose and effect of each drug, and the necessary precautions. The printed recording sheets now have full instructions. Following this recent visit the manager sent details showing that all staff that handle drugs have attended a medication course within the last year. Previously the manager had to be reminded to make sure all relevant people such as social workers and key nurses – are kept informed if there is a significant event. At this visit the manager said that this was happening. She demonstrated this by listing those who had been consulted about the recent move-in, covering both residents’ family and representatives. She also described attendance at a recent CPA review meeting for the established resident. Minutes of that meeting had not yet arrived, but the manager showed the detailed entry she had made in the day-to-day notes. The requirement set in the last report on this matter has been achieved. Compass Grove DS0000027840.V284301.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. In line with the requirements set in previous reports, the inspector asked the manager about her understanding of adult protection procedures. At this visit she was able to give adequate explanations and show that she had copies of the main guidelines. EVIDENCE: The last couple of reports have said that it is essential that the manager had a clear grasp on the actions to follow if there is an allegation or concern. There have been some incidents, such as a theft about a year ago. At this visit the manager was able to locate and describe the significance of key documents such as the local adult protection guidelines and ‘No Secrets’. She confirmed that attendance on training covering this topic is included in the portfolio she submitted as part of gaining the NVQ level 3 award. The requirement covering this matter is therefore met. Compass Grove DS0000027840.V284301.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): 24,25, 26, 27, 28, 29 and 30. The house is well maintained and suitably furnished in a contemporary style. It is neatly arranged throughout, suiting the residents’ choice to have a neat and ordered living environment. Both residents showed the inspector their bedrooms, each saying they were satisfied with their room, and the house overall. EVIDENCE: The ground floor is a spacious open plan lounge-diner, with a separate wellfitted kitchen. The bedrooms are suitably furnished, and reflect the tastes and interest of the two residents. There is a spacious bathroom with a shower beside the bedrooms on the first floor. The rear garden has a patio with furniture. The premises were again found to be bright, airy, and clean. An independent infection control and hygiene audit gave the commendable score of 91 . The last inspection by an EHO was on 7 April 2004. Three minor recommendations were made, but the report concluded that it was “a very clean well run home”. A support frame has been introduced into the bathroom the help the new resident with a slight mobility problem. No other adaptations are needed. Compass Grove DS0000027840.V284301.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 and 35. These standards were covered in the last report. This home now has relatively good continuity, there being better staff retention within the company generally since the last round of inspections six months ago. EVIDENCE: In addition to the manager who routinely covers shifts, there is a core of four part-time care workers. Routine cover is one person on each shift, including waking night cover. There are handover overlaps between the three shifts. At this visit there was one full-time post vacant, with interviews booked for the following day. The last report asked for better records to be available covering this team’s training and qualifications. The ‘action plan’ said that all staff files now had an individual training record, saying when core topics had been covered. At this visit the inspector asked for copies of these to be sent to him. There are still quite a few gaps, and a lack of detail, though there are ticks to say where a copy of a certificate is held on the file. The manager did say which courses had been booked for the following month. Although most of the main core areas are listed, there is not enough detail on the ‘tracking sheet’ to confirm compliance with the requirement set on this matter. That requirement is repeated, and this area will be looked at again at the next visit. Two staff are understood to be doing NVQ level 2. The manager said they had been offered support from the company, but both had already commenced, having made their own arrangements. Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 17 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. The owners have given assurances that they will support the manager progress with her training in order to broaden her skills and gain the required qualification. Both service users are able to make their choices known and comment on the quality of service they receive. EVIDENCE: Christine Mitrovic has worked for the company for nine years. She was previously the senior support worker at Compass Lodge. She took on the manager’s job at Compass Grove in February 2004.Her registration has been confirmed. She has now completed the NVQ level 3 award. She intends to progress onto NVQ at level 4 and the RMA. Following this inspection, the owner Dr Sharon Davis called the inspector and outlined the plans to support Christine Mitrovic proceed with this training, including the company identifying a tutor. The owners and managers do carry out spot-checks, including at nights, and take action where they find deficiencies. The owners use a tick and comment ‘monthly report’ format produced by the NCHA, and have done business plans. Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 18 At announced inspections the owners have made available information from their accountants confirming the viability of the business. At the visit six months ago 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. The last time a fire safety inspector visited he reported no problems. Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 19 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 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 X 35 2 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 2 X X 2 X 3 X X X X Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes – Items 1 and 2 are 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 YA19 Regulation Requirement Timescale for action 30/04/06 2 A32YA35Y 3 YA37 17(1)(a)Schd3(3)(m) Maintain accurate records of all medical consultations and tests. Ensure that all staff are aware of the system for recording these in the service users’ files and make entries on the correct sheet. 18(1)(c) Provide staff with sufficient training to ensure that they are qualified and competent to support the needs of service users. Maintain a clear record of each staff member’s qualifications and training. 9(2) Provide the Commission with a plan setting out the timescales and support being provided to the manager to achieve an appropriate qualification. 30/04/06 30/04/06 Compass Grove DS0000027840.V284301.R01.S.doc Version 5.1 Page 21 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 Grove DS0000027840.V284301.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. 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