Inspection on 14/06/05 for Compton House

This inspection was carried out on 14th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Compton House 30/08/06

Compton House 11/10/05

Compton House 09/02/05

Compton House 22/04/04

Similar services:

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Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

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Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Compton House Otterbourne Road Compton Winchester Hampshire Lead Inspector Isolina Reilly Unannounced 14/6/05 09:30am 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 Older People. 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. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Compton House Address Otterbourne Road, Compton, Winchester, Hampshire, S021 2BB 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) 01962 712086 Mr Martin Kenneth Peake Mrs Miriam Long CRH 12 Category(ies) of LD- Learning Disability: 12 registration, with number LD(E)- Learning Disability over the age of 65 of places years: 12 Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1- Service users in LD category must be at least 50 years of age. Date of last inspection 9/2/2005 Brief Description of the Service: Compton House provides care for up to twelve male and female older service users over the age of 50 with learning disabilities. Three Directors own the home privately with Mr Martin Peake as the registered individual and Mrs M Long as the employed registered manager. The home is situated in a quiet rural outskirts of Winchester. Local services and amenities require transport to access although there is a local garage and shop within reasonable walking distance. The Home hires appropriate transport and staff cars are available to access the community. The building is a double storey domestic in style house, comprising of two large single bedrooms and five large double bedrooms. The home’s communal space comprises of one lounge, additional open plan sitting area and a separate dining room. Compton House is surrounded by substantial parkland and has large gardens with it’s own resident family of deer, providing additional recreational space and parking. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The staff and some of the service users spoken with preferred to be identified as residents rather than service users. This inspection took place over one day as part of the normal regulation and inspection programme. The opportunity was taken to look around the home, view records, procedures and talk with residents and staff. The inspector also had the opportunity to observe lunch being served, and interaction between residents and staff. Eight residents and four members of staff were spoken with to who told the inspector what they though the home was a good home. What the service does well: What has improved since the last inspection? The home has developed a new system for recording care needs for the residents that is in the process of being transferred over. This makes the information staff need to care for individuals clearer and more logical. A new Chef and cleaner have recently been employed by the home that has released the care staff to spend more time with the residents. The home presents as a homely, comfortable and suitable environment for the residents because of the on going redecoration and replacement of carpets. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 6 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. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6 The admission process is well managed and residents/carers are given appropriate information regarding the service. The home does not provide ‘Intermediate Care’. EVIDENCE: Three residents files were sampled and discussed with in the manager. The manager confirmed that no new residents have been admitted since the last inspection and explained that residents’ families and Social Care professionals had viewed the home prior to individual coming to stay. Some of the residents asked them questions about how they wished to be looked after, their likes and dislikes and that they could come to the home as a trial to see if they liked it. On arrival they all were made welcome, shown around the home and introduced to other residents and staff. The files sampled showed that a full assessment had been recorded prior to and on admission for both residents. These records reflected the information given by the residents spoken with. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 9 All the residents spoken with confirmed that they liked the home, felt comfortable and safe. The manager confirmed that the home does not provide ‘intermediate care’ rehabilitative short-term type care for Social Services. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The residents are well looked after in respect of their personal and health care needs in such a way as to promote privacy and dignity. There is a new improved care planning system in place providing staff with the information they need to meet residents’ needs. Links with the community are good and enrich residents’ social and cultural opportunities both within the home environment and external. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: The residents spoken with were all very happy with the care provided by the home. Stating that staff are nice and helpful. The inspector observed staff and the manager interacting with the residents respectfully and mindful of their privacy and dignity. There were staff around most of the time in the communal areas participating in one to one games and other activities like jig saw puzzles and counter games. The three residences whose file had been sampled confirmed that they feel comfortable and well cared for at the homes. The staff confirmed spoken with Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 11 confirmed that they discuss the residents’ care needs regularly with them at a level that they can understand and by use of observation. The manager explained that the home is in the process of implementing a new system for recording care plans that clearly identifies the risk assessment, goals and care instructions for staff. The inspector was able to sample two care plans that had been transferred onto the new system. The risk assessments, goals and actions were clear and reflected the care needs identified in recent Social Services care needs assessments. The staff spoken with felt the system was better and easier to follow. They also confirmed that the manager had involved them in the development and implementation of this new system. Currently the staff and the manager are looking into improving the daily record keeping and shift handovers systems. The manager confirmed that she has planned to have all the care plans transferred onto the new system within the next two months. The individual records also included names of relatives, friends, health care professionals and social services care managers who are involved in supporting the resident. A resent photograph was seen on all the files and records of instructions on care when dying and death. There were also records of doctor and nurse visits and information on outpatient, dental, optician and chiropractic appointments. The home administers medicines direct from the pharmaceutical boxes. Staff were observed administering medication appropriately and the good medication administration practices are reflected in the homes policy and procedures that were briefly sampled. A copy of the Royal Pharmaceutical Guidelines for residential care was available. The receipt, administration and disposal records of medication were seen by the inspector and found to be satisfactory. The manager showed the inspector the home’s medication storage cupboard that was clean with medication stored correctly in date and in sufficient quantities. The manager confirmed that the home has historically placed topical creams are stored separate to other medication and is planning to review this practice with the pharmacist on their next visit. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The residents experience a stimulating and varied life at the home with visitors encouraged, various formal and informal structured activities are made available including outings. The home has excelled in providing a changing programme of activities that meets the residents’ aspirations. The meals in this home are good offering both choice and variety, catering for special dietary needs in very pleasant setting. EVIDENCE: The inspector observed several residents reading magazines with appropriate soft music in the background. A member of staff supporting one resident to play ‘Connect Four’ and another staff supported a resident to complete a jigsaw puzzle. The residents spoken with said that they liked the music. They also confirmed that they take part in several activities like quizzes, carpet games and reminiscing and they also enjoy going out to social functions. The home has weekly activities sheets and records in the individual care plans which activities are participated in and whether the resident enjoyed them. The inspector sampled the activities schedules and they included attending the Salvation Army, local church, lunch clubs, going for walks feeding the ponies. The home offers weekly exercises by an instructor that many of the residents attend, there are also art and craft classes and the inspector observed the Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 13 latest art project displayed on the dining room wall. The home also offers aromatherapy, reflexology, sewing classes, drama group evening functions and swimming. The staff and residents spoken with stated that the routines are flexible. One resident said that they were able to go out for walks and feeding the ponies. The manager and staff confirmed that the recruitment of a new Chef and cleaner has released staff to spend more time with residents on a one to one. The new chef spoken with explained how the home caters for special diets mainly diabetic and showed the inspector the records held within the kitchen. The storage of food within the home was found to be satisfactory. However, it was noted that the two freezers kept in the garage were difficult to access as they were sited at the back of the garage and the casing looked rusty. The chef confirmed that temperatures for these two freezers were not recorded. The manager and chef gave verbal undertaking to ensure that temperatures were recorded starting immediately and that the freezers would be relocated to the front of the garage facilitating access. The manager confirmed that the home has a routine pest control contract and the inspector was able to sample the correspondence from the company. All the residents spoken with found the food very good and that there was always a choice of meals. The staff were observed asking the residents which meal they would like as the meal were being served. The meal was observed by the inspector and found to be relaxed, unhurried and the food attractively presented at tables. The menus were varied and planned several weeks in advanced. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints procedure that residents are able to use. The staff have an understanding of Adult Protection issues that protects residents from abuse. The home has an open and positive approach to listening to residents and staff views and improving. EVIDENCE: The residents were very clear how and to whom to complain to if they are not happy. They all stated that the staff are good and kind. The inspector sampled the home’s complaint procedure and found it to be satisfactory including the address for the Commission and that all complaints will be dealt with promptly within 28 days. The home’s has received no complaint to date. All the residents spoken with stated that they always felt safe at the home. The staff spoken with confirmed that they have received some instruction and are aware of the protection of abuse of vulnerable adults. The manager and staff have attended training recently. There has been one unsubstantiated allegation of suspected abuse at this home that was appropriately referred and recorded. However, there appeared to be a slight delay in staff reporting their concerns. This was addressed as a matter of urgency the home and subsequently all staff have received up date training in the Protection of Vulnerable Adults. The home has a copy of the Hampshire County Council ‘Protection of Vulnerable Adults’ policy and procedure. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 15 Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home presents as a clean, homely, comfortable and suitable environment for the residents. The standard of the décor within the home is adequate with evidence of on-going maintenance. EVIDENCE: The staff stated that the home is always clean, warm and no offensive odours were detected. The residents stated that they liked their home and it was nice. The staff also confirmed that there has been on going decorating including the first floor bathroom, one double bedroom and down stairs toilet. The manager confirmed that the maintenance and redecorating schedule had prioritised the toilets and then the hallways. The residents spoken with stated they liked their bedroom just as they were. All the bedrooms were seen on a tour around the home and were found to be clean, bright and warm, furnished to the individuals taste and many had been personalise. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 17 During the tour of the home the inspector noticed that all the communal hand sinks have returned to using bars of soap and towelling hand towels. The manager explained that they have one resident that is going around taking the liquid soap containers and hiding them their wardrobe and stuffing paper towels down toilets that resulted in the main drainage system for the village becoming blocked. The manager stated that a system for routinely replacing towelling hand towels and checking liquid soaps will to be implemented as a matter of urgency and to establish strategies with the resident to reduce inappropriate behaviour. Disposable gloves and aprons were available around the home and staff stated that they use them appropriately. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The staff at the home are appropriately trained, supported and employed in sufficient numbers to meet the residents’ needs. The home has recently increased the staffing level to include a Chef and cleaner and this is reflected in the staff being able to spend quality time with residents. There are good recruitment procedures that are fully implemented and ensure that the level staff on duty does not put the service users at risk. The owners of the home have demonstrated by lack of action that the employment documentation for staff working at the home has a low priority. EVIDENCE: The service users spoken with described the staff as ‘caring, kind and nice. The inspector observed that the staff were with the residents throughout the day. The staff spoken with stated that they felt there were sufficient staff on duty each shift to meet the residents’ needs. However, one staff member felt that during the afternoon shift the workloads were such that there was less time to spend with residents on one to one activities, although this was not necessarily the view of other staff spoken with. This subject was raised with the manager who confirmed that afternoon workloads would be discussed at the next staff meeting to identify the issues and solutions. A staff member sated that the other staff supports the new staff. The manager confirmed that a work place risk assessments has been completed on a staff member that is pregnant. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 19 The rotas showed that a minimum of three care staff were on duty each morning and two in the afternoon and evening shifts and one waking and one sleeping in night staff each night. The staff spoken with felt that the recruitment process within the home is thorough. The inspector was able to sample three different staff records and found that they were detailed with the necessary checks had been taken to ensure staff are fit to work at the home and correctly stored. The staff spoken with stated that they have been working at the home for some time and recall that the induction programme run by the home was useful. The files sampled held records of the individual staff home’s own induction’ training covering the key areas with the signatures of the staff member and trainer. The manager confirmed that the home invested in an external induction system that complies with the Skills for Care minimum standards of induction. The two new staff have a training schedule that includes this induction. The staff spoken with confirmed that the home continues to provide and support staff to achieve qualifications in care to National Vocational Qualification level 2 and 3. The home’s training records show that the staff undertakes training both internally and various external training courses including Protection of Vulnerable Adults, Bereavement, Autism and the Learning Disability Awareness Framework. The staff confirmed that they undertake training regularly. The inspector was able to sample training certificates and other records of training undertaken by the staff. The local community psychiatric nurses will also come and give informative talks and assist with training in specific/specialised resident care needs. The home has a positive supportive attitude to staff training. The records also show that staff have received training in relevant health and safety subjects including food hygiene, moving and handling, fire safety, first aide and safe handling of medication. The records sampled showed that regular staff supervision was being undertaken and most staff spoken with confirmed this. However, one staff member was not sure if she had had supervision. This was discussed with the manager who presented the supervision records for the particular staff member. The manager confirmed that she would address the lack of understanding regarding what constitutes supervision with the individual. It was noted on sampling the staff records that the staff had no signed contracts of employment on file. This was discussed with the manager who stated this was an on going problem with the owners of the home. The employment contracts were amended some time ago and been checked Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 20 however they have yet to be disseminated. The manager confirmed that she is regularly prompting the owners to issue the contracts. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 The home provides an auditable system for managing or monitoring residents’ moneys. The home is in the process of improving the temperature recording systems for fridges and freezers. The residents’ health, safety and welfare are appropriately promoted by the home to ensure everyone is protected. The general risk assessment recording for the building has lapsed. EVIDENCE: The manager confirmed that the residents’ money is kept secure with in a locked cupboard and in one of two safes. Each resident’s money is kept separate in a clear plastic wallet that also contains all receipts and logbook of all activity with signatures. The records of one resident were sampled and the money was counted in front of the inspector and found to be correct. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 22 The manager confirmed that the responsible individual is nominated signatory for one resident. At the resident’s recent review of care by Social Service it was agreed that Social Service will agree receivership proceedings so that the responsible individual will then have no signatory powers for residents’ money. The home keeps daily records of foods served and temperatures of hot probed meals and fridge temperatures for the fridge and freezers within the home but not for the two freezers kept in the garage. The maintenance records within the home were sampled and found to be satisfactory. However, it was noted that the building general risk assessment has lapsed. The manager confirmed that this would be completed as a matter of urgency. The records sampled evidenced that visual checks on fire safety equipment, emergency lighting are undertaken regularly and the fire alarm tested weekly. The staff spoken with and records sampled evidenced that the staff have regular fire safety instruction and drill practices. Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 2 Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 24 No 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 38 Regulation 13(4)(c) Requirement The home must ensure that the environment is resaonably free for hazzards. The genreal buildings risk assessment must be up to date and appropraitely recorded. Timescale for action 01/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 25 Commission for Social Care Inspection 4th Floor-Overline House Blechynden Terrace Southampton Hampshire 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 Compton House H54 S11878 Compton House V232363 140605 .doc Version 1.30 Page 26 - 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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