Inspection on 05/09/06 for Compass Lodge

This inspection was carried out on 5th September 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Compass Lodge 21/02/06

Compass Lodge 06/09/05

Compass Lodge 11/03/05

Compass Lodge 05/01/05

Compass Lodge 04/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

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 Lodge 121 Abbs Cross Lane Hornchurch Essex RM12 4XR Lead Inspector Mr Roger Farrell Key Unannounced Inspection 5th September 2006 11:15 DS0000027841.V311226.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000027841.V311226.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000027841.V311226.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Compass Lodge Address 121 Abbs Cross Lane Hornchurch Essex RM12 4XR 01708 502179 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 4 Category(ies) of Learning disability (4) registration, with number of places DS0000027841.V311226.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: Compass Lodge provides accommodation and support to four people who have learning disabilities. The owners operate two further smaller homes in the neighbourhood. Historically one manager has been responsible for this house, and Compass Cottage, a short walk away further along Abbs Cross Lane in Hornchurch, and this remains the case. Compass Lodge has been operating for over ten years. The property is a semi-detached house, set back from the busy road. The front entrance has steep circular steps, but easier access is possible at the side, including a narrow ramp to a side door. The communal room is a combined lounge diner. The dining area is a bit cramped and has poor natural light, but overall the home is quite homely. All residents have single bedrooms, with one on the ground floor and three upstairs. These are well decorated and reflect the individuality of each person. There is a small rear garden with a patio. The former garage to the side has been split to create a laundry and storeroom, with the other half converted as the office. The neighbouring property is a sub-post office and shop. Good standards of cleanliness are maintained, and this is a consistent finding at unannounced visits. This home is about a mile from the shops and other facilities of Hornchurch town centre. DS0000027841.V311226.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on Tuesday 5 September 2006, between 11:15am and 6pm. Jo Smith, the manager, was available to take the lead in dealing with the inspector’s questions and showing him the necessary paperwork. She has arranged the records in a much better way, including a guide for staff to follow if an inspector calls when she is not there. The manager had not received the ‘pre-inspection’ form sent in mid-July, and a replacement has been sent. She is aware of the changes taking place in the way homes are monitored, including carrying out internal quality checks - and from next year, the home’s ‘quality rating’ being published. The inspector spoke with all service users, and is appreciative of the welcome he receives. He also met with a group of four staff. The manager has sent details of relatives’ current details and questionnaire have been sent out. The inspector has spoken to the relatives of all residents at or since last year’s visits, and they have his contact details, as is the case for two residents social workers. He was also grateful to have met the advocate who was visiting the home. All the main core standards were covered at this visit What the service does well: This home has shown steady improvement under the leadership of the current manager. Initially her best efforts were frustrated by high staff turnover. The headline positive finding at this inspection is that much better stability is now the case, with staff turn-over having been reduced considerably over the past eighteen months. A number of staff are people who have worked at the Compass homes previously, and have returned. This is true of this home’s deputy, and other senior staff in the company. This home’s strength has been that it has a strong tradition of making sure residents are well supported with their day-to-day living needs, and household standards such as cleanliness are consistently found to be good. There are mutual benefits from being close to the other Compass homes. For instance, service users from these two houses pop-in regularly, meaning that there is a wider social network, including going to evening clubs together. One quite able resident from a nearby Compass home is a good friend and support to the two women who live at the Lodge, including helping teach Makaton signs. Other positive points have been the ‘Women’s Group’ get-togethers, and arranging holidays – a two residents were going on a four-day break to a seaside resort the following week. DS0000027841.V311226.R01.S.doc Version 5.2 Page 6 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. DS0000027841.V311226.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000027841.V311226.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service. This included receiving confirmation about the assessment and move-in procedures that would be used when there is a vacancy. EVIDENCE: The ‘statement of purpose’ file includes photos, and the ‘service users guide’ uses simple language with ‘widgets’. There is now more rotation of staff between the three Compass homes. The inspector has asked the manager to include the normal pattern of shift cover in each individual home’s ‘statement of purpose’. There was the likelihood that one resident may move to another home. This means that there would be a vacancy for the first time in over four years. Last year the inspector said that he wanted the company to have much clearer procedures on assessing new residents, how move-ins are arranged, and clarifying the central decision-making responsibility of the registered manager. He has been shown the set of procedures that will now be used, and the manager of this home gave assurances on this matter. This includes the NCHA’s standardised ‘application form’ and the ‘assessment schedule’ – and a ‘pre-service and needs assessment’; ‘trial periods’; ‘admission procedure’; and move-in checklists’ adopted from the ‘Mulberry’ series. These set out a responsible approach to introducing prospective residents. The steps that will be followed with any new person referred for a place are covered in the DS0000027841.V311226.R01.S.doc Version 5.2 Page 9 ‘statement of purpose’. The assessment standard is rated as met as it accepted that the company will follow these guidelines in the future. The manager confirmed that Compass homes do not accept emergency admissions. There are contracts covering each person’s terms of residency, with a copy on each resident’s main file. The current range of fees for the Compass group of homes is £800 to £1,400 per week. DS0000027841.V311226.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service and looking at ‘service user files’. There has been a steady improvement in the way care plans are kept, but making sure there are reviews still needs to be improved. EVIDENCE: There has been a gradual improvement is how ‘service user files’ are arranged and kept up-to-date. This has included introducing sections that seek to establish the choices of residents, such as the ’likes and dislikes’ and ‘what I need help with’ – with good use of photos and pictures. The files are arranged in a uniformed clear sequence with a front index sheet. The main section of the files is a series of ‘care-plan’ sheets covering a range of general headings, including health; mental health needs; mobility; personal care; communication skills, and so on. These identify individual needs, and then set out the support that is needed, including giving practical guidance. There are now monitoring sheets saying these are checked, and if necessary updated each month. As suggested last year, there are now risk assessments covering specific areas such as going out and using the kitchen. The manager has also slimmed down these main working files by transferring older paperwork to the archive ‘mirror DS0000027841.V311226.R01.S.doc Version 5.2 Page 11 files’. Useful information that has been kept on the main files includes the ‘communication passports’ that were done by one of the owners who is a speech and language therapist. However, the inspector said that it is best to keep the last report from each health care worker on the current files. Previously each service user’s file had a copy of a review with their social worker and relatives carried out within the last year. There were also premeeting resumes using the main headings from the care plans. However, at his last visit the inspector was concerned that these ‘annual reviews’ had lapsed, and a requirement was set to bring these up-to-date. This has not happened. The manager explained the steps she had taken with each resident’s social worker and others to make sure a review was booked - but there is a need to repeat this requirement. For instance, agreement about why and how one resident should move on to another home had become confused and controversial – yet a review meeting to discuss this major change had not taken place. Further, the manager and staff said that this resident is often reluctant to leave the building, but the social worker said that there had not been sufficient effort to support a busier lifestyle. The manager needs to write to social services if an annual review is overdue, saying a date must be set. They also need to do an in-house review report at least once a year, where appropriate, discussing this with the service user and their relatives. The manager and team have been dealing with a sensitive matter to do with one person’s contact with their family. Contact between the home and the social services department had become strained. The inspector had said that there was now a need to involve an independent advocate to help the service user express her wishes. An independent advocate had started visiting this person. Further, the inspector said that if a move on was to take place, then there must be a suitable handover of information as part of the transition arrangements. The resident with the highest dependency needs was due to have a review. The inspector said that this person’s mobility needs must be discussed and agreement reached on the level of help in moving around when out. Earlier advice said that use of a wheelchair should be avoided so as not to increase dependency, including outside the home. However, staff said that this was severely restricting the options of using community facilities as even with assistance she could only manage short distances on foot. Recently her family had provided a wheelchair, but staff were unsure of when this could be used. The manager agreed that much clearer understanding was necessary on this important matter. This may need to involve getting an occupational therapist to do a fresh assessment. DS0000027841.V311226.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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. Quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to the service. There were examples of more opportunities for activities, though this still remains an area that needs to be improved. EVIDENCE: Three of the residents have quite high support needs, such as with personal care and going out. One person is nervous about leaving the building at times, and staff need to be flexible in responding when he chooses to go out or when he decides to head home. Another person has limited mobility. The fourth person can do more for himself, but also needs someone with him when he goes out. Relatives have raised the need for residents to have more activities. There is evidence that things are moving in the right direction. For instance, the most dependent resident has a visiting art therapist twice a week, and she was at the home on the day of this visit. Other plans include spending time at stables, and trampoline sessions due to start locally, as well as going on a short holiday break. However, as stated above the mobility issue needs to be tackled. DS0000027841.V311226.R01.S.doc Version 5.2 Page 13 The most able resident is quite active – regular activities include a part-time job, playing badminton and an exercise session. He was due to go on his third holiday this at the end of the week. Two other residents have been attending the keep-fit sessions at the local sports centre. Going to two evening clubs remains popular with all four residents, as well as a monthly disco. There is now an activity log in the lounge, and the manager sent a list of recent outings. The manager is aware that planning activities remains an area needing development, though the initiatives being taken at present is acknowledged. The manager gave an overview of each residents contact with their family members. There have been difficulties in one relationship, but three residents continue to have regular positive contact. The two residents who could give a view on the standard of meals said they were satisfied, and were asked about their preferences. A third resident also indicated that she was happy with the meals served on the day of this visit. There is now a practice of laying out options in the kitchen and asking those who use few words to indicate what they want. There were good stocks of food, including fresh vegetables. The manager gave assurances that the resident who needs soft food was receiving sufficiently varied and suitably presented meals. A further swallowing assessment had been carried out the week before and new guidelines were expected. Staff now steam-cook items such as vegetables and fish. A record is kept of the meals each person has had that day. DS0000027841.V311226.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 ‘good’. This judgement has been made using available evidence including a visit to the service and looking at the medical details in files. There is a good tradition of involving health care professionals and monitoring well being. EVIDENCE: The care-plan files have a ‘my medical details’ section, with tracking sheets for contacts with doctors and other health care workers – though the inspector said that it is important to carry forward the date of the last appointment when a new sheet is started, as a couple of sheets were blank. On the day of the visit two residents were being accompanied to optician appointments. All residents need to be accompanied to all medical appointments. The two GP practices used are described as helpful. There are a good range of assessments and reviews from health care workers, including a psychiatrist, occupational therapists and physios, as well as the speech therapy ‘passports’ referred to earlier. The most recent report from each type of health care worker should be kept on the current file rather than the archive ‘mirror file’. The medicines cupboard was moved from the outside office to the hall last year. The medication administration files have individual profiles, and DS0000027841.V311226.R01.S.doc Version 5.2 Page 15 instructions to follow if an error occurs – though no mistakes are known to have occurred in the past year. A local pharmacist supplies medication in blister packs, with printed administration sheets. This pharmacist also provides two-stage training sessions, and all staff have to complete a competency test before being responsible for giving drugs. The pharmacist visits and checks the medication arrangements about every three months and leaves a report – though such a check was now overdue. DS0000027841.V311226.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service. The manager and owner are good at keeping the inspector informed when issues arise regarding these standards. EVIDENCE: There is a file in the office 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 adult protection guidelines. All staff but the most recent joiner have attended training on protection procedures led by one of the owners and completed an evaluation form. Previous reports have said that the manager and owners have correctly followed the necessary procedures when there has been a suspicion. The owners carry out unannounced visits, including ‘out-of-hours’ visits with the manager. They have a good record of acting on concerns, such as a staff member found sleeping, and a concern raised by a resident at one of the sister homes. They were currently in contact with Havering Council’s protection manager about a complex matter. The manager was keeping the inspector upto-date on the issues. Only one complaint had been received this year. This was about a resident’s hairstyle, and the manager had followed through the arrangements with the family. The manager explained problems to do with one resident not being able to get money out of his bank account. A new account had been opened with a friendlier branch, and that person’s social worker was pursuing the matter with the previous bank. DS0000027841.V311226.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service, and seeing all areas including bedrooms. The building is adequately maintained, but there are a few outstanding minor safety defects and some areas now need to be scheduled for redecoration. EVIDENCE: This home is a semi-detached property set well back on a rise away from the busy Abbs Cross Lane. The neighbouring property is a sub-post office and handy general store. The house is generally well maintained, with good housekeeping standards remaining a consistent finding at unannounced visits. The combined area of the lounge/diner provides space that exceeds the minimum required level. These are comfortably arranged with a good range of homely touches, including photos, and entertainment equipment. Kitchen hygiene standards were also satisfactory. The last inspection by an environmental health inspector in March 2006 described conditions as “generally satisfactory”. However, a couple of improvements were asked for in sealing the work surface joints and securing handles, but these had not been done. Also, a fire safety inspector who visited in July 2006 said the kitchen light fitting connection needed to be changed, but this also had not been done. DS0000027841.V311226.R01.S.doc Version 5.2 Page 18 The owners have a good record of responding to safety advice, but on this occasion it has been necessary to set requirements telling them that they must deal with the recommendations made at safety inspections. The manager said that she had recent discussions with the owners about a schedule of redecoration for the main rooms, including the kitchen when outstanding defects would be tackled. The inspector was shown each person’s bedroom. All have a good standard of cleanliness and décor and show a high level of personalisation, such as photos, trophies, and home entertainment equipment. The bathroom is on the first floor beside the three upstairs bedrooms. There is a shower room on the ground floor with a toilet and hand washbasin. For a couple of years the owners have said that they were going to install a walk-in shower as it is believed that this might suit one resident who has problems using the existing shower cubicle. The inspector had been told that this work was due to be carried out soon after his last visit in February. This has not happened. The owners make commitments regarding the upkeep of the premises in their ‘Five Year Business Plan’, but there is now a need to have a more specific schedule of works. This needs to include sorting out the laundry room as it has become cluttered, and maintaining the garden such as dealing with the overgrown decking area. Nevertheless, overall the home remains comfortable and clean, with good attention to important areas such as helping residents keep their bedrooms tidy, and good support with clothes care. DS0000027841.V311226.R01.S.doc Version 5.2 Page 19 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): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service that involved looking at records covering staff vetting and training, and meeting with a group of staff. The positive headlines are that the significantly improved level of staff retention is continuing, and most staff are achieving qualifications. EVIDENCE: For sometime there has been an overlap between the staff that work in this home and at Compass Cottage. Over recent months most staff now do shifts in all three of the Compass homes. Because of personal care arrangements, male staff only work at the Lodge. Also, new staff tend to start at the Lodge as there are always at least two people on duty. The staffing complement for Compass Lodge and Compass Cottage combined is – manager; 2 full-time deputies; 2 full-time senior care assistants; and 4 full-time and 7 part-time care assistants, of which 4 cover night shifts. Cover in this house is 2 staff on duty on the early and late shifts (7.30am to 10.00pm), with a 30-minute afternoon handover. The manager’s hours are additional to this level of cover, normally being 9 to 5 on weekdays. Night cover is one waking person. Current rotas show occasional ‘long-shifts’, though these are said to be voluntary, and are followed by a day off. The manger, deputy and owners provide ‘out-of-hours’ on call backup. DS0000027841.V311226.R01.S.doc Version 5.2 Page 20 The major improvement in this service is that staff turnover has decreased significantly over the past eighteen months. Reports from over a year ago said staff throughput was a major problem, and this had been raised as a matter of concern by relatives who spoke to the inspector. Now, nearly all staff have been at the home for at least a year, with only one person leaving during this period. All posts are filled, and a number of staff are people who previously worked at the Compass homes and have returned. This corresponds with staff telling the inspector that there are much better working relationships. Comments by staff at this visit included – “There is a good atmosphere. Staff get on well together, and that includes the manager and (senior staff).”; “Yes, there is good support. We all get on okay. We can provide support when a new person joins and help them understand the clients.”; One newer staff member said – “I heard about the job through word of mouth. I found everyone really helpful, and it has been better than I had expected.” This increased stability means that the record on training and qualifications is much better. Staff spoke about how they have done training on the main core areas such as fire safety, medication, manual handling and food hygiene. Staff files have training log sheets, and copies of certificates. Of particular note is the success being achieved supporting staff to complete the main national qualification for care-assistants. The target of having 50 qualified staff has just been achieved, with nearly all other staff having started doing the award. One staff member was having his final on-site assessment on the day of this visit. Staff files have a copy of the induction checklist, signed when each topic was covered. However, the inspector did say that too many topics were covered with one joiner over her first two days – this induction having been carried out at one of the other homes. Reasonably regular staff meetings are occurring, and these are now for staff from all three of the company’s homes. Staff files have typed notes of supervision notes, which include looking at training needs. However, the regularity of supervision needs to be increased to achieve the advised minimum stated in the NMS. The good record on carrying out adequate staff vetting is being maintained. This includes getting two written references; having copies of documents that prove identity; checking permission to work; and having a fresh CRB certificate for all employees. The only gap was the need to have a clear recent photo on each staff file. Gaps due to holidays and sickness are covered by established ‘bank staff’ who have done the induction programme. DS0000027841.V311226.R01.S.doc Version 5.2 Page 21 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. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service that involved looking at records covering safety checks. Some requirements have been listed on safety arrangements, but overall conditions are satisfactory. EVIDENCE: The manager has over fifteen years experience in the care sector, nine 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, and is awaiting confirmation of the RMA Award which she completed in June 2006. The owners and manager 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 brief business DS0000027841.V311226.R01.S.doc Version 5.2 Page 22 plans. At announced inspections in the past the owners have made available information from their accountants confirming the viability of the business. The improved arrangements in the office means that presenting the records inspectors ask to see are now much more efficient. At this visit this included the paperwork covering fire checks and drills; electrical and gas safety; and insurance cover. The fire log is well maintained, but the fire safety inspector has asked for there to be a premises ‘fire risk assessment’ in line with new regulations. The other gap is the need to have a water safety check, including a Legionella test. Other than the need to tidy-up the storage area in the laundry room, no other matters were raised at this visit. DS0000027841.V311226.R01.S.doc Version 5.2 Page 23 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 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 3 X X 3 2 DS0000027841.V311226.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes – Item 2 on arranging reviews is repeated. 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 YA1 Regulation 4 Requirement Timescale for action 13/11/06 2 YA6 3 YA12 YA13 YA14 4 YA19 Include in the ‘statement of purpose’ the level of staff cover on shifts. It is also a requirement to include the current level of charges. 15(2)(b) At least once a year hold a meeting with relevant professionals, family or other representatives that reviews the service and facilities being provided to each service user. Have a record of these meetings on the service user’s file. This must include specific support needs such as help with mobility and what aids are appropriate. (This requirement is carried forward from the last report.) 16(2)(m)(n) Include in care plans, and agree at review meetings the support that will be provided to each resident to take part in social, educational and leisure activities. 17/Sched 3 Keep on the current service users’ files details of the most recent appointments and reports with doctors and other health care workers. DS0000027841.V311226.R01.S.doc 13/11/06 13/11/06 13/11/06 Version 5.2 Page 25 5 6 7 8 YA24 YA24 YA24 YA28 23(2)(d) 16(2)(j); 23(5) 23(4) 23(2)(l) 9 10 YA34 YA36 19(4)/ Sched 2. 18(2) 11 YA42 13(3) Have available a redecoration schedule. Complete all advised works set out in reports received from the environmental safety team. Complete all works set out in reports received from the fire safety inspector. Make sure that items are safely stored in the laundry area and that there is adequate working space. Include in staff files a recent clear photo. Provide all staff with regular supervision. This should be at least six times each year, and maintain a record. Have available a water-safety report, including tests for Legionella prevention. 13/11/06 13/11/06 13/11/06 13/11/06 13/11/06 13/11/06 13/11/06 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 DS0000027841.V311226.R01.S.doc Version 5.2 Page 26 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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