Inspection on 09/05/06 for Compass Grove

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Compass Grove 21/02/06

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 9th May 2006 11:00 Compass Grove DS0000027840.V293978.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.V293978.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.V293978.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.V293978.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 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.V293978.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 on Tuesday 9 May 2006, between 11.30am and 4.50pm. Christine Mitrovic, the registered manager, was available to help with the inspector’s checks. There have been changes to the way care homes are inspected. The manager has been given an overview, and has read the letter setting out these changes. This includes asking the owners and manager to show how they are monitoring the service and planning improvements. From next year this will include giving homes a ‘star rating’. The inspector is grateful for the welcome he receives from the residents, and the helpful way they give views on the support they receive. He also appreciates the comments made by relatives and health care professionals who were available to speak to him. These views have helped the inspector arrive at the conclusions in this report – the main one being that there is still a high level satisfaction with the service and facilities provided. The manager gave a commitment that in the future she will reply on time when asked for information. Questionnaires have been sent out to relatives and health and social care professionals, and these comments will be included in the next report. Residents, relatives and professionals know they can contact the inspector if they have a particular concern. There were two unannounced inspections over the previous year – on 30 August 2005 and 21 February 2006. Copies of inspection reports are available at the home, or can be seen on www.csci.org.uk. What the service does well: With the exception of a three-month period in 2003, the established resident had not shared this home since she moved-in 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 in February 2006. The inspector visited a week later and spoke with both residents together and separately. They both said that they were very happy with the change. All the indications about this new house-sharing arrangement were positive. 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 Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 6 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.” Nearly three months on the arrangement is still working very well. The new resident spoke about how well she had settled, and felt much more relaxed as she found she was getting into arguments in her previous home. She said – “I am very happy here…There is nothing I can think to change. I like it as it is.” The main community nurses said that they were involved in planning and monitoring the move-in, one comment being – “I did support the move. We did share information and have meetings (with the homes’ staff)…The two women get on well, and it is going fine.” One relative who visits regularly added – “I know it has worked out well. {My daughter} is very happy with the arrangement.” What has improved since the last inspection? What they could do better: The major shortfall is the failure to maintain adequate personal support records. Good initiatives have been started in the past, but this manager has yet to show that she is able to operate a system that covers the following key elements: Assessment – these must cover the areas set out in Standard 2.3; Care Plans – these must say what has to be done to support an identified need; Monitoring – as appropriate to a particular individual, a running record of aspects of identified need, such as contacts with health care professionals, blood tests, weight charts and so on. Day-to-day notes saying what help has been provided are also a part of monitoring. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 7 Reviews – a periodic record that the service user’s needs have been reevaluated to match their current needs, including discussion with the services users and others such as relatives, the psychiatrist, community nurses and social workers. Also, service user files need to include risk assessments appropriate to each person’s areas of vulnerability, such as going out, mood changes and history of seizures. It is also important that the registered persons make sure that where they have said improvements have been achieved – such as having safe medication arrangements and making sure there is sufficient training - that these can be shown to be carried through and are consistent. They also need to pay particular attention to where requirements have been carried forward – as is the case with all three requirements from the last report. A failure to deal with these matters can lead to enforcement action. 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.V293978.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.V293978.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): 1, 2, 3, 4 and 5. The quality rating in this area is adequate. The practical arrangements covering the move-in of the resident from the neighbouring house were satisfactory. However, this did not include doing fresh assessments. The manager needs to improve the standard of records, including making sure key documents such as the ‘statement of purpose’ is up-to-date. EVIDENCE: Last year 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 who has moved in and staff in her new home knew each other well as she would visit Compass Grove 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 is being held open for three months to be extra sure that the new house-sharing arrangement works out. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 10 Minutes of the pre-move review meeting are available. This shows good planning, though it is surprising that the care manager had not been told ahead of the meeting that a move was to be proposed. Nevertheless, all the signs are that the new arrangement is 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 has been sensitive as the established resident had ‘the home to herself’ over such a long period, though she has consistently said that she wanted a housemate. Standards 3 and 4 are scored as met. The failure to keep residents’ files up-to-date is covered in the next section. This includes not taking the opportunity to carry out any fresh assessment of support needs. It is recognised that that there was a high level of familiarity in this instance - but just moving the care file from one house to another is not enough to show proper assessment as spelled out under Standard 2.3 in the National Minimum Standards (NMS). The manager must recognise her responsibility to make sure there is the required range of practice notes, including recent assessments. Equally, it was now time to hold the new resident’s three monthly review, but this had not been booked. Therefore a requirement has been set on doing proper assessments. There are copies of contracts on the residents’ files, and the owners have copies of the standard contracts issued by Havering and Newham Councils. The ‘statement of purpose’ needs to be updated as this has not happened since this manager took over. The ‘service users’ guide’ makes good use of photos – but now also needs updating. The manager needs to look at the NMS and regulations and make sure all the necessary information is covered. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 The quality is this area is adequate. This home continues to be successful in its primary purpose of helping the two residents have settled and safe lifestyles. However, it is not succeeding in having practice files that show a methodical approach to planning support and monitoring. Overall, this weakness is holding the service back in the year leading up to the publication of ‘star ratings’. EVIDENCE: Both residents speak up for themselves and are able to make decisions about their lives, such as how they want to spend their time. They also have good practical life skills. Indeed, one of the benefits of the sharing arrangement is that this has encouraged the established resident to use more living skills, such as helping get meals ready. As well as providing companionship and keeping an eye on domestic routines, both residents need a carer with them when they go out. Residents tell the inspector that they do speak up if they are unhappy about something, and say whom they would turn to if they had a big worry. Both have said that they can talk to the manager, and also mention the manager and deputies of the two other homes. For instance, one resident said how helpful she found the deputy from Compass Lodge following her recent bereavement. Relatives and professionals confirm both residents do raise issues. The inspector is confident that the manager, staff and owners do act Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 12 when the residents say something is bothering them. For instance, residents recently heard two staff members have an argument outside the home. This matter was followed up, and one person was transferred to another house. Standards 7, 8 and 9 can be scored as achieved. The inspector’s major criticism is the failure to have an up-to-date system of support plans. The manager and team continue to provide good day-to-day support with daily living, including monitoring moods and making sure the residents are safe in the house and when they go out. A former manager had set up an excellent system of assessment, care planning, monitoring, and liaison over two years ago. There have been other more recent initiatives in the other two Compass homes to introduce a ‘person centred care plan’ system. There has also been a strong tradition of maintaining good links with a wide range of professionals, such as the psychiatrist, community learning disability nurses, speech and language therapists and so on. Both residents’ support needs have largely stayed constant, but the ‘in-house’ information is now dated and the files are bulky with old material. Other than keeping day-to-day notes and a couple of brief sets of guidelines drawn up by one of the owners, nothing has been done to update the new resident’s file handed over from the home next door. Even basic adjustments such as changing the address on the ‘missing person’s form’ have not been tackled. Important information from others, such as recent psychiatric reports and minutes of reviews had been slotted in, but overall both files need a major overhaul. The manager had just made a start on updating care plans. She said that she had only recently agreed ‘management time’ with the owners - that is time in the week when she was freed-up from being the ‘duty staff member’. She said that the owners had given her full permission to use additional staff cover, and initially she intended to use one day a week for such tasks as updating the practice files and providing staff with supervision. When she accepted the manager’s post the owners gave an undertaking to support her develop the necessary skills. She speaks positively about the help she gets from the ‘area manager’. The owners and ‘area manager’ need to make sure she has help bringing the practice files up-to-date. Standard 6 covering this important area is scored as ‘partially met’. The home has a small office that is locked when staff are not using it. There is also a lockable filing cabinet. There were problems last year when the manager did not keep others informed of a couple of significant events, but she has since said that is no longer the case – including having a main contacts list in the office. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 13 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): 11, 12, 13, 14, 15, 16 and 17. The quality rating in this area is rated as good. Both residents have good living skills, are able to say how they want to spend their time, and speak up if something is not right. They receive good support to be involved in worthwhile activities such as doing jobs and attending social events. EVIDENCE: Both service users have active lifestyles. There is an up-to-date programme showing each person’s regular planned activities. Over the years both have attended a range of ‘skills for life’ college courses, and have shown the inspector their certificates. They have now graduated from all such courses available locally. One resident does a part-time job in a charity shop three days week. She talked about how friendly her colleagues are, and how she has been happy to increase her hours. The other resident had just started working part-time in a café. Both regularly attend a couple of evening clubs, and discos. They also go on quite regular outings, and occasional holidays arranged by the clubs. One resident goes to a gym, with the other person being encouraged to start going Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 14 again. There is also a ‘women’s group’ for those who live in the three Compass homes some Sunday evenings. Since they completed their college courses both residents have less fixed commitments during the week. One resident said about her current planned activities – “Its about right at the moment. I do enough, the time I do at the shop is about right. I still like being a Makaton tutor (to a resident at Compass Lodge).” The established resident decided that she did not want to go on a short holiday break that was planned for last summer. The inspector was shown a list of outings and holiday breaks that were being talked about for this year. Both residents have strong links and regular contact with their families, including one who stays with her Dad one night a week. In his last report the inspector said a priority was to make sure that both residents had the necessary level of support to continue their busy lifestyles. When there was only one resident it was not a problem for the duty staff member to go out with the resident, including at short notice. Having the two other homes nearby is handy as other staff can help, or a resident can spend time at the Cottage or the Lodge if a staff member is out with the other person. The inspector asks residents about these arrangements, and is told that this works well as there are good friendships between the residents of the three homes. For instance, at this visit one resident said - ”If {my housemate} doesn’t fancy going to the club this evening I can always pop up to the Lodge and go with them in the taxi.” The residents take a lead in choosing their meals. Staff help them do their own shopping, and both make sensible decisions about picking good ingredients, including fresh fruit and vegetables. One resident has talked to the inspector about watching her weight. Family and health care workers said that the other resident needs more help with her diet as she is gaining weight. Help with a healthy diet is an area that the manager needs to cover in the revised care plans. Nevertheless, all the evidence is that the assistance provided with food shopping and cooking meets the residents’ needs, and Standard 17 - as with the other items under this heading – is rated as satisfactory. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. There is good support from health care professionals, including attending the residents’ main reviews. The shortfalls under this section are again mainly to do with maintaining accountable records. Procedures need to be tightened up, such as making sure all aspects of dealing with medication meet the necessary standards. EVIDENCE: Residents have good self care skills, and generally only need minimal guidance from staff about personal care and looking after their cloths and bedrooms. One resident has a minor disability, but a support frame around the loo and a shower chair means that she can use the bathroom without help. It was disappointing to find a couple of failings under these headings in areas raised in previous reports as needing improvement. Good links are maintained with medical services – the psychiatrist and community learning disability team provide good consistent monitoring and back-up. Yet it was again found that the medical contact sheets were not being kept fully up-to-date. These are tracking sheets that record contacts with medical practitioners, such as the psychiatrist; GP; dentist; optician; chiropodist and so on. This is the way that the manager can demonstrate she is making sure these health areas are being monitored. For instance, the inspector observed that one resident needed foot care. A different chiropody service now needs to be used, but there was no Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 16 record that this had been followed up. This is another example of how this service is failing to maintain proper records. Unless there is an improvement in this important area by complying with requirements notified in reports, then legal action will be taken against the registered persons. 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”. A significant problem was found at this visit. The manager had altered the printed dose details on the administration sheets. She explained that the psychiatrist had reduced this item, that she had informed the pharmacist and gone to the GP surgery to confirm this alteration – but the GP’s instructions had still not be changed two months later. The extra pills were still arriving in the loaded bubble cassettes. Staff were taking one pill out of that bubble section, then having to sellotape the surplus pill back in. To make matters worse, a couple of week’s supply of spare capsules were in the pharmacy returns box that was not locked away in the office. As with the lack of instructions found at an earlier visit, the manager needs to be more assertive in making sure that medication instructions are correct. This may need to involve phoning the psychiatrist or community nurse, or writing to the GP saying an error is happening – rather than the sort of improvisations and safety lapses that were evident in this instance. Confusion over the right dose have occurred in the past, therefore the manager must take quick action to sort out such problems. The registered persons need to make sure that tighter medication monitoring systems are in place. For instances, the supplying pharmacist is really helpful in providing staff with training. She should be asked to carry out ‘spot checks’ of the medication arrangements in this house as part of a community pharmacy contact. As first stage legal action was take last year regarding medication, the registered persons need to be aware that further lapses can result in enforcement action. The manager showed the inspector her returns log that is signed and stamped by the pharmacist proving that surplus medication is being returned. Some guidance is available, such as what to do if there is an error or when a resident is going away for the night. However, there needs to be a main set of guidelines specific to this home. The inspector has sent the manager some information to help draw this up. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 17 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 quality outcome in this area is good. The manager can now show that there is sufficient awareness to respond if a complaint or concern is raised – including having copies of the main guidelines readily to hand. EVIDENCE: Last year’s reports said that it is essential that the manager had a clear grasp of the actions to follow if there is an allegation, concern or complaint. There have been some incidents, such as a theft from a resident over a year ago. The manager is now able to describe the steps that must be taken in such instances, including having available key guidelines such as the local adult protection guidelines and ‘No Secrets’. She has confirmed that attendance on training covering this topic was included in the portfolio she submitted as part of her NVQ level 3 award. Information is available on how to make complaints, including how to contact an advocate. An advocate has been asked to help in the past. Both residents tell the inspector who they would speak to if they had a worry. No complaints have been logged over the past year. One sensitive issue raised a couple of months ago was followed through. Assurances have been received that all staff have been given a copy of the General Social Care Council’s code of practice, and told about the phased scheme for all care workers to sign up. The last time the inspector met with a group of staff from the Compass homes they showed they were aware of this, and knew the meaning of ‘whistle blowing’. Staff training profiles list that most have attended the training provided by one of the owners on protection safeguards, and there is a training video on this topic in this home. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 18 The manager explained the systems for helping residents with their money. Extra safeguards are in place because of the theft eighteen months ago. The owners have always called in the police if there is any suspicion of financial irregularities. The manager holds both residents’ bank books, and goes with them every fortnight to withdraw their rent contribution and personal money. Running accounts are kept of each time a resident receives money, with receipts of purchases. The manager double-checks these, and residents’ cash balances are checked and signed for at every handover. The manager confirmed that residents do not have to cover any staff expenses, such as staff meals being claimed from petty-cash when they go to a café with a resident. However, the manager said there are some inconsistencies in whether the occasional take-away meals are paid for out of petty-cash or by the residents themselves. She needs to clarify this matter. The inspector checked with the recent resident who said that she still has the same amount of personal money as was the case before she transferred. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 19 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 quality rating in this area is good. Both residents are very happy with the home’s facilities, including their personalised bedrooms. The house is comfortable, clean and safe – and the overall quality of the building is another strength of this service. 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 each resident. There is a spacious bathroom with a shower, beside the bedrooms on the first floor. One resident said how pleased she was with her home entertainment set-up and showed the inspector how it works. She was appreciative of the help one of the owners had given her set her bedroom up as her new bedroom is a bit smaller. The house was again found to be bright, airy, and clean. The last independent infection control and hygiene audit gave the commendable score of 91 . An environmental health inspector recently checked the kitchen on 31 March 2006, their report saying that conditions were ‘All satisfactory’. Their previous report had concluded - “a very clean well run home”. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 20 A support frame has been fitted around the loo, and there is a shower chair to help the resident with a slight mobility problem. One of the owners has also fitted an extra sturdy rail along the staircase. No other adaptations are needed. The owners have done a forward plan covering redecoration of their three homes. This house is now showing a few signs that some redecoration is due, such as the kitchen ceiling. The only blot is that the garden now looks neglected. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 21 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, 33, 34, 35 and 36. The quality in this outcome area is adequate. The manager leads what is a relatively stable and consistent team. Where problems arise, including issues raised by residents, action is taken. Better staff retention in the company overall means that they now need to improve their training record and quota of qualified carers. EVIDENCE: Routine cover is one person on each shift, including waking night cover. There are handover overlaps between the three shifts. Each home has a copy of the rotas for the other two homes so they know who is available, and staff keep in touch during shifts such as saying when they are going out. A headline theme in the Compass homes’ inspection reports was the high staff turnover. However, the last round of reports said that staff retention had improved considerably over the past year. This home was the least affected as, in addition to the manager, it usually has a core of four regular carers. Only women staff work in this home. Recently, one person had left and another had been moved to the neighbouring house. It is good news that the core group of workers at this home have all been in post for at least a year. One full-time person had joined this team, having worked at the Lodge for eighteen months. However, the manager said that the owners were intending to increase the rotation of staff between the three homes. Gaps in the rota are always covered Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 22 by the regular pool of workers, including familiar bank staff. One resident said that she was pleased that her former ‘keyworker’ does occasional shifts in this house. As staff are on duty on their own in this home, the expectation is that all staff have had a full induction and covered the main core training areas, as well as having been fully vetted. They must be over twenty-one. The last inspection report said that there needed to be more detailed records of staff induction, training and qualifications. The manager has sent the inspector each core staff member’s individual training profiles. These now have better detail - such dates, who provided the training, and if a copy of the certificate is on file. There has been good progress in keeping staff files that show that the required range of checks have been carried out. Most staff files are kept at the Lodge. The inspector did a random check a couple of months ago, and these were satisfactory - including having two references, a CRB certificate, and checking permission to work. These well arranged staff files had a training profile, induction checklist and copies of course certificates. At this visit to the Grove two staff files were checked. These were satisfactory, but the registered persons are reminded that they must get a fast-track ‘Povafirst’ return while they await the full CRB certificate, even if the person has had a recent check by another company as was the case in one instance. The inspector asked why there were no staff contracts/terms and conditions on these files. The owners are reminded to of their legal obligations on this matter. The expectation is that 50 of staff should be qualified, mainly having gained the NVQ level 2 award in care. A couple of the core workers are currently doing this course which they have arranged themselves. The ‘area manager’ has been carrying out ‘training needs assessments’, and more staff from within the group of three homes have started doing NVQs. However, even with greater rotation of staff, the company are not yet meeting the qualifications target. Improved staff retention means that the registered persons can be more confident in forward planning to help staff gain the necessary qualifications. Staff files have copies of some supervision sessions. The manager said that the agreement for her to have allocated ‘management time’ means that she will be able to provide more regular supervision, and is aiming to achieve the target of at least six sessions a year. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 23 Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The quality rating in this area is adequate. There has been a gradual improvement in the manager accountability, and how some record systems are arranged. The efficient presentation of safety paperwork at this unannounced visit is a good example. The owners need to follow through the commitments they made to make sure the manager is given support to develop her skills. EVIDENCE: Christine Mitrovic has worked for the company for ten 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 was confirmed last year. She has completed the NVQ level 3 award. She intends to progress onto NVQ at level 4combined with the Registered Managers Award. Following the last 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. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 25 Christine Mitrovic confirmed that she has been enrolled to do the manager’s qualification through Havering College’s ‘distance learning scheme’ – and that a tutor has been allocated – and she will start in September this year. These details need to be confirmed, as asked for in the repeated requirement. The manager of the other two homes, Jo Smith, acts as ‘area manager’. She meets with Christine Mitrovic once a week. 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 basic business plans. Later this year the Commission will send out a standardised quality assurance schedule that the registered persons will be asked to complete and send back. Providers may also be asked to produce a detailed ‘improvement plan’ where there are still a lot of requirements being listed in reports. At announced inspections the owners have made available information from their accountants confirming the viability of the business. The manager said that there is always a good petty-cash float, and sufficient money to cover shopping and other expenses such as buying replacement electrical appliances. At this visit the inspector asked to see a range of records and certificates covering health and safety. This included weekly tests of the battery alarms and the fire drills; contractor tests of the extinguishers; and electrical and gas certificates. These were all satisfactory. The last time a fire safety inspector visited he reported no problems. The manager does periodic fire safety audits and keeps these on file. One of the owners does general building health and safety checks as part of his visits, and tackles minor repairs. Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 2 X 2 X 3 X X 3 X Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? Yes – the first three items 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 17(1)(a); Schd3 (3)(m) Requirement 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. 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. Provide the Commission with a plan setting out the timescales and support being provided to the manager to achieve an appropriate qualification. (Received 12 May 2006.) Make sure that the ‘statement of purpose’ and ‘service users’ guide’ is up-to-date, including details of the manager and staffing cover. Carry out the required range of assessments on all prospective service users, and update as required. These need to be included in the service user’s file. DS0000027840.V293978.R01.S.doc Timescale for action 30/06/06 2. YA32 18(1)(c) 30/06/06 3. YA37 9(2) 16/06/06 4 YA1 4;5;6 30/06/06 5 YA2 14 30/06/06 Compass Grove Version 5.1 Page 28 6 YA6 15 7 YA20 13(2) 8 YA20 13(1)(2) 9 YA20 13(2) 10 YA34 17(2)/ Schd4 (6)(f) 18(1) 18(2) 11 12 YA35 YA36 Maintain an up-to-date service user’s file. This must include assessments; care-plans; monitoring; reviews; and risk assessments. Have available guidelines that set out the procedure and arrangements for the ordering, storage, handling, administration and return of medication. Liaise with the GP and pharmacist to make sure the instructions and supply of medication is correct. Make sure all medication is safely locked away, including surplus stocks awaiting return to the pharmacy. Include in staff files a copy of the signed terms and conditions of employment. (Letter received 12 May saying these are to be issued.) Have a training plan that shows how the target of 50 trained staff will be achieved. Provide staff with individual supervision, and keep a record. This should aim to achieve six sessions each year. 30/06/06 16/06/06 16/06/06 16/06/06 30/06/06 30/06/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Compass Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 29 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 Grove DS0000027840.V293978.R01.S.doc Version 5.1 Page 30 - 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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