Inspection on 06/09/05 for Compass Lodge

This inspection was carried out on 6th September 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Compass Lodge 05/09/06

Compass Lodge 21/02/06

Compass Lodge 11/03/05

Compass Lodge 05/01/05

Compass Lodge 04/03/04

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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 Roger Farrell Announced Inspection 06 September 2005 11:00 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 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 Stationary 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 Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Compass Lodge Address 121 Abbs Cross Lane, Hornchurch, Essex RM12 4XR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01708 502179 Compass Residential Homes Ltd Ms Joanna Martine Smith CRH Care Home 4 Category(ies) of LD Learning Disability (4) registration, with number of places Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11 March 2005 Brief Description of the Service: Compass Lodge is a private registered care home that accommodates and supports four people who have learning disabilities. The owner’s operate two other 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 nine 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 pleasant rear garden with a patio, and a small decked area. 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 subpost 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. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home had an announced inspection on Tuesday 6 September 2005, between 11am and 5pm. The other two homes in this group had unannounced visits the previous week. The manager of Compass Lodge is also responsible for Compass Cottage, and as ‘area manager’, also overviews Compass Grove. She had been present for the inspections a week earlier, and promised to have a range of paperwork available at the announced visit. This included the files of staff who work across the homes. A positive finding is that all these records were available and up-to-date, including those covering safety arrangements and the care plan files saying what help the residents receive. The inspector was also able to meet with a group of staff, including the deputy. Four staff also sent written comments, as well as a visiting activities organiser. Five relatives returned questionnaires, meaning that at least one family member of each resident gave views. The inspector appreciates this help. He is also very grateful for the warm welcome he receives from the residents, and for the chance for them to show him their bedrooms. The inspector said that he was disappointed with the inadequate ‘action plans’ received in response to the last inspection reports, particularly how the problem of staff turnover was avoided. Nevertheless, a favourable finding of this round of inspections was that the manager was able to show that all the areas raised in the previous reports had been progressed. What the service does well: The resident who has lived at this home since 1995 has quite good independence skills. The other three residents have greater needs, two of whom use few words. This is quite a stable and relaxed household, with a good level of friendship and tolerance within the resident group. However, maintaining basic day-to-day care has at times been under strain due to problems within the team, and staff leaving. Poor staff retention was the headline concern last year. It now appears that a better level of consistency is possible, and this was reflected in the manager’s renewed enthusiasm to consolidate and develop this service. She was particularly pleased that a valued deputy returned after a six-month break. The standard of practice files continues to improve. There was also evidence that a more planned approach was being taken to help the more dependant residents gain life skills, and have better opportunities beyond just support with domestic routines. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 and 5. The inspector was shown the guidelines on assessment and move-ins that would be followed should a vacancy occur. This would need to make sure any new person would get on with the existing residents. EVIDENCE: There is laminated ‘statement of purpose that covers all areas, including the registered persons’ details and the size of all rooms. The inspector has also seen the much improved ‘service users’ guide’, now presented in a clear style, including using symbols and photos. There have been no new admissions to this home since March 2002. The inspector had been shown the documentation ready to be used in future for assessment should a vacancy occur. This included the NCHA’s standardised ‘application form’ and the ‘assessment schedule’. However, earlier in the year the inspector raised major concerns about the poor planning around an attempt to quickly move a new resident into Compass Grove. He asked the company to have a much clearer policy and procedure on assessment and move-ins, clarifying the central decision-making responsibility of the registered manager. At this visit he was shown a series of documents that he was assured would be used as the framework in the future. These include a ‘pre-service and needs assessment’; ‘trial periods’; ‘admission procedure’; and move-in checklists, all adopted from the ‘Mulberry’ series. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 9 These set out a responsible approach to introducing prospective residents. The assessment standard is rated as met as it accepted that the company will follow these guideline in the future. The manager said the homes do not accept emergency admissions. There are now contracts covering each person’s terms of residency. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, and 9. The gradual improvement in how service user files are maintained helps show that day-to-day care is now better planned. Progress is also underway to demonstrate that skills training is taking place and residents are being helped have some more opportunities to broaden their lifestyles in line with their choices. EVIDENCE: The ‘Service User File’ format introduced last year is a significant improvement and are much better organised in line with the front index sheet. These are modelled on the ‘person centred planning’ approach, and have sections that seek to establish the choices of residents, such as the ’likes and dislikes’ and ‘what I need help wit 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. The manager still in effect acts as ‘keyworker’ for all residents, though better staff retention over the past four months means that some specific support tasks are now allocated in supervision. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 11 There were copies of reviews on the files seen, the manager saying there had been a main review for each person with their placing social services during the past year, there being pre-review in-house resumes. More recently ‘skills teaching monitoring forms’ had been introduced, but these did not yet have sufficient detail to be of much use. The manager also referred to introducing a ‘My Life Plan’ section. The gradual improvement in introducing more up-to-date practice notes is welcomed. However, the main gap is not having risk assessments, such as for the person who has mobility problems. A requirement has been set on this matter. However, her file did have a quite recent physiotherapist’s report. The manager discussed in detail two practice issues. One involved a maintaining the personal hygiene of a resident who is distressed by using baths and showers. This involved recent contact with her family. Installation of a walk-in shower is being considered. The other related to the need to have staff present when one person had contact with her family due to a recent incident. One relative wrote – “Generally the home gives good care to the residents with the most important basics, such as general care, cleaning and activities. They do their best to give residents a good quality of life.” One of the registered owners is a practicing speech and language therapist and a Makaton tutor. Care-plan files contain communication assessments, which she had carried out. The manager is able to clearly describe each resident’s communication abilities. Two residents have limited verbal skills, though sections in the care plan files showed good efforts to establish preferences and determine how choices may be expressed. Communication cue cards are available. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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 standard(s) 12 and 13. There are good signs of a better approach to helping residents have a wider range of activities. This is positive, but this remains an area that needs to be developed further. EVIDENCE: As stated above, this service’s scope has been limited in the past due to problems maintaining a stable staff team. This has meant that maintaining day-to-day domestic routines was generally all that could be achieved. Three of the residents who live here have quite high dependency needs, such as with personal care and going out. One person is nervous about leaving the building, and needs a flexible service to respond when he chooses to go out. Another person has limited mobility. Some relatives again raised the need for residents to have more activities, including going as something they would like to see. At this visit there was some evidence of a step in the right direction. For instance, the most dependant resident now has a visiting art therapist once a week, and is also going out for an art session. There is an ‘activities plan’ and notice board in the lounge, and sheets recording what who has taken part in the programme. The ‘service user files’ have better details about social and leisure activities, such as reports from holidays and outings. The manager said – “I Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 13 think activities are one area that is taking off due to the better staffing situation.” A good example was the photos of the weekly ‘women’s group’ for those who live in the three Compass homes. Another resident made cakes during the visit, saying that this is an activity that she now enjoys doing regularly. This trend of improvement is very welcome. The inspector and manager spoke of how the service could develop by helping residents, notably those with higher dependency levels, have more opportunities providing the staff cover situation stays stable. These standards will be looked at in more detail at he next visit. The manager described each person’s level of contact with their family. The meals standard was not covered in detail at his visit. The inspector was told that the resident who needs a soft diet was offered separately pureed portions. However, when asked, staff who prepare some meals were not aware that separate blenders were now available. Again, the inspector will check up on the arrangements for meals in greater detail at his next inspection, including the arrangements for special diets and helping one person who needs help watching his weight. Details of the ‘Havcare’ advocacy service are available. An advocate visits about every six-months, and would be called if a specific issue arose. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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 standard(s) 18, 19 and 20. Details kept on file, including the ‘tracking sheets’ and reviews show good monitoring of health care needs. The care plan sheets are good at specifying what help each person needs with their personal care. EVIDENCE: The care-plan files have a ‘my medical details’ section, with good tracking sheets for contacts with doctors and other health care workers. All residents have seen an optician and dentist in the past year, though one resident is very frightened of the dentist and a recent visit had to be cut short. All residents need to be accompanied to all medical appointments. The two GP practices used were described as helpful. Files have a good range of assessments and reviews from health care workers, including psychiatrist, occupational therapists and physios, as well as the speech therapist referred to earlier. The manager described the progress that had been made helping one resident regain better mobility, including introducing walking aids. Progress means that specialist nurses no longer routinely visit. The medicines cupboards have been moved from the outside office to the hall. The arrangements for storing and recording medication were are found to be satisfactory, but the manager was reminded to return items no longer needed. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 15 The medication administration files now have individual profiles, and instructions to follow if an error occurs – though no mistakes are known to have occurred in the past year. Medication is supplied by a local pharmacist in blister packs, with printed administration sheets. This pharmacy also provides training sessions, and all staff have to complete a competency test before being responsible for giving drugs. The pharmacist checks the medication arrangements about every three months and leaves a report. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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 standard(s) 22 and 23. The manager is aware of the expectations about recording, reporting and following through on complaints and any suspicions of abuse. The necessary range of guidance is available, and staff gave clear answers when asked about their responsibilities on protecting residents. EVIDENCE: The inspector was shown the revised basic complaints policy, that now includes contact details for the Commission. Assurances were received that there is now only one ‘complaints book’ available, that is kept in the office. There have been no complaints recorded over the past year. There is available a file containing the required range of policies and guidance covering protection issues and responses. This includes a copy of ‘No Secrets’; the in-house policy and ‘Pavilion pack’; and the Havering guidelines. Longer serving staff have staff have signed to say they have attended briefing and video sessions and are familiar with the key documents. A training session for more recent staff planned for the previous week had to be cancelled. Assurances were given that this would be quickly rescheduled. All staff have signed to say that they have been given a copy of the main ‘code of practice’, and those who met with the inspector gave good answers about their responsibilities, including on whistle blowing. The manager had followed the guidelines following an incident with a visiting relative. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 and 30. The house is well maintained and kept clean. The good standards were confirmed by an independent infection control and hygiene audit carried out last year. EVIDENCE: This semi-detached property is 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 premises is generally well maintained, and was found to be bright and clean - which is a consistent finding, including at unannounced checks. The last inspection by an EHO was in April 2004, with conditions recorded as ‘satisfactory’. A Fire Safety Inspector checked arrangements in June 2004, his report recording good safety arrangements. 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. The kitchen was found to be clean and safely arranged. The garden has a small patio with furniture and a separate small area of decking. The laundry is part of the former garage, with a separate section used as the office. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 18 The inspector was shown all bedrooms. 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, adjacent to the three upstairs bedrooms. There is a shower room on the ground floor with a toilet and hand washbasin. The shower is a cubicle with a step-in base. There is a plan to change this to a walk-in version. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36. Keeping staff was the main problem raised in the last report. The signs at this visit are that the situation has improved, but monitoring this important part of providing the service still needs to be monitored by the registered persons. EVIDENCE: There is considerable overlap between the staff who work in this home and at Compass Cottage, with seven care assistants doing some shifts in both homes. The last reports on these twinned homes raised the major problem of staff retention, one staff member had summed this up by saying - “I think the care is quite good, {but} things are affected by the staff situation. It is annoying when good people say they’re leaving. It affects us, and must be confusing for the residents. It takes time to understand the needs of our residents who don’t have verbal conversation….. you’re not here very long before you are showing someone new the ropes.” Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 20 The report went on to say -“Staff turnover remains the prominent factor restricting the consolidation of this home. At the announced inspection the manager gave a profile of each staff member, including each individual’s training and experience. The problem is illustrated by the fact that when the inspector returned ten weeks later almost 40 of established staff had left or were due to leave….The registered persons must carry out a critical analysis of this matter, and are invited to make comments in the action plan that has been requested in response to this report.” The brief response received sidestepped this issue, saying nothing worthwhile about how this problem was to be addressed. At this visit the manager went through the staff list. With one or two exceptions, most had been with the company for less than six months. The inspector was told that about three months ago the owners did a staff questionnaire. However, no outcome or proposals were known, including about the issue of how wages are paid. Nevertheless, the manager said that the signs are that the rate of throughput is slowing. Those staff who spoke to the inspector, all of whom were quite recent, talked of there being good unity, which is an important reason why they would stay at a home. Another positive point is that the manager is very pleased that the valued deputy has returned to that post after six-month break, and he is able to help with management tasks like supervision. Therefore, the indications are that the situation has improved, but this is an area that the inspector will continue to monitor. The staffing complement for Compass Lodge and Compass Cottage combined is – manager; deputy; assistant deputy manager; 1 senior care assistant; 9 full-time and 4 part-time care assistants, of which 4 cover night shifts. Cover in this house is 2 staff members on duty on the early and late shifts (7.30am to 10.00pm). Night cover is one waking person. Staff said that regular planned and minuted staff meetings are taking place about every four weeks. The manager is good at carrying out the required range of vetting - such as getting two references, a CRB certificate, and checking permission to work. The well arranged staff files have a training profile, induction checklist and copies of course certificates. This reflects the positive steps that have been taken over the last couple of years to have records that meet the standards. The inspector told the manager that she needs to keep her management knowledge up-to-date, such as how to get ‘Pova-first’ clearance. There was also a much clearer plan and support for helping staff gain a relevant qualification, mainly using the NVQ scheme offered by Barking College, though the team are still well below the target of having 50 of qualified staff. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 21 Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 41, 42, and 43. Good evidence was at this visit to support the standards tested under this heading. The manager is based at this house for most of the time, visiting Compass Cottage a couple of times a week. The presentation of records covering health and safety were much more efficient compared to previous visits. EVIDENCE: The manager has fourteen years experience in the care sector, seven 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. After some delay, she is due to start doing the registered manager’s course in September at Barking College. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 23 The owners and manager 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. At announced inspections the owners have made available information from their accountants confirming the viability of the business. The inspector asked to see a range of records and certificates covering health and safety. This included tests of the alarms and quarterly fire drills; contractor tests of the fire alert system and extinguishers; electrical and gas certificates; and information on Coshh materials. These were all satisfactory. The one area needing improvement is to carry out more regular in-house health and safety checks as these had lapsed since the end of last year. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x x 2 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Compass Lodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 3 3 3 3 G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 13(4)(c) Requirement As appropriate, include in service users file risk assessments in key areas such as mobility needs within the home and when going out. Have in place clear guidelines covering any special dietry needs, and make sure staff are fully following such instructions. Promptly return all discontinued medication to the pharmacy, or by means of any alternative approved disposal scheme. Ensure that staff have sufficient training in the core areas, and that there is a plan working towards the target of staff holding a recognised qualification. Carry out regular health and safety checks of the building and grounds, and maintain a record. Timescale for action 9/10/05 2. 17 16(2)(i) 9/10/05 3. 20 13(2) 9/9/05 4. 32 18 9/12/05 5. 43 13(4)(c) 9/10/05 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 Good Practice Recommendations G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 26 Compass Lodge Standard 1. Compass Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex 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 Lodge G55_S0000027841_Compass Lodge_V240496_060905_Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!