Inspection on 10/01/06 for Compton Lodge

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Lodge 23/08/07

Compton Lodge 14/12/06

Compton Lodge 23/07/05

Compton Lodge 17/02/05

Compton Lodge 21/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Compton Lodge 7 Harley Road London NW3 3BX Lead Inspector Ms Pippa Treadwell-Smith Unannounced Inspection 10th January 2006 10:00 X10015.doc Version 1.40 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 Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Compton Lodge Address 7 Harley Road London NW3 3BX 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) 020 7722 1280 0207 586 8113 eileen.salem@ccht.org.uk Central & Cecil Housing Trust Eileen (aka Ellen) Salem Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd July 2005 Brief Description of the Service: Compton Lodge is a two storey Edwardian House that has been extended and adapted to provide accommodation for 34 older people. The home is owned and managed by the Central and Cecil Housing Trust. The house is situated in a quiet residential area close to Primrose Hill. The home is convenient to shops, amenities and public transport with the nearest tube station being Swiss Cottage. The house is set back from the road and surrounded by mature gardens. There are 30 single rooms and two shared rooms all of which have an ensuite facility comprising of a toilet and a hand washbasin. There is a television aerial socket and a telephone point installed and each room is linked to a call bell system. Each room is furnished with a single bed, armchair, wardrobe, chest of drawers and a lockable bedside cabinet. All the radiators are low surface temperatures to meet health and safety requirements. On the ground floor there are four sitting rooms and one dining room. Access to the first floor is via stairs or a shaft lift. There are assisted bathrooms and toilets on each floor. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in January 2006 and lasted about 5 hours. It was the second inspection for the inspection year 01.04.05 to 31.03.06. The main focus of the inspection was to assess the remaining key standards that had not been looked at during the previous visit. The manager was available to assist the inspection and the inspector had the opportunity to talk to service users and look at the relevant records. This visit also looked at the progress, which had been made in meeting the requirements, which were recorded at the previous inspection. What the service does well: What has improved since the last inspection? What they could do better: Areas where the home could be doing better were discussed and agreed with the manager. The home needs to demonstrate more involvement by service users and their relatives in developing care plans. The audit carried out by the providers and by the inspector showed that the care planning systems needs to be improved. The outcomes of complaints need to be recorded and passed onto the person who made the complaint. Staff need accredited training in the administration of medication and generally training records need to be kept updated. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 6 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 Lodge DS0000010330.V250388.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 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 the following standard(s): These standards were not assessed. EVIDENCE: Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7, 9 & 10 Only limited progress has been made in developing a clear and consistent care planning to adequately provide staff with the information they need to satisfactorily meet the needs of service users. There are adequate arrangements in place to ensure that the medication needs of the service users are being met however training is required. Personal support is offered in such a way as to protect the service users’ privacy and dignity. EVIDENCE: The registered providers carried out a quality audit on 1st December 2005 on a sample of care plans. The audit identified a number of areas for improvements because of gaps in the information. During the audit care plans were looked at in detail. Three did not have adequate assessments; there were no separate care plans for religious and cultural needs; social needs of the service users require separate care plans; wishes for dying and death were also not recorded on a separate plan. Monthly evaluations were not being completed and the audit advocated that service users and their relatives are involved in developing care plans. With the intervening festive season and a depleted management team, there has been little progress in implementing the recommendations of this audit. A sample of four care plans was taken during Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 10 this visit. The inspector’s findings were similar to those of the quality audit. One-service users was admitted on 23.11.05. The care record showed that there had been a significant weight loss. Her care plan recorded that the service user enjoyed food especially sweet things but preferred small portions. There are no monthly reviews recorded and no references made to the weight loss. Another service user’s care plan was in the new format but this had not been completed. A further two care plans were looked at and neither had social profiles or monthly reviews recorded. The home has a medication policy and procedure, which includes the sevenday rule and the action to be taken in the event of non-compliance with the policy. Included in the policy is a listed of GP approved homely remedies. The policy acknowledges that only staff who are competent and had received training will be eligible to administer medication. Annual refresher is said to be available. Discussion with the staff member who was administering medication highlighted that she was a long-term agency member of staff who had received in house training only. There are no training records to verify this. Medication is stored in a locked room with air conditioning so that an ambient temperature can be maintained. Medications are administered using a Nomad system and stored in a medicine trolley. Controlled drugs are held in a padlocked metal cabinet. There were no controlled drugs being administered at the time of the inspection. An inspection of the trolley showed that a bottle of eye drops had been opened and stored in the trolley but there was no date when the drops had been opened either on the bottle or the MARS sheet. This potentially puts the service user at risk, as the medication will only last for 28 days from the date of opening. The core values of privacy and dignity are contained within the home’s philosophy of care and form part of the home’s in-house induction. Privacy and dignity are recurring themes, which are reflected in the home’s policies and procedures. The care plans have spaces for the service user’s preferred name and these are usually filled in. All the service users have single rooms and there are locks to both bathrooms and toilets. Staff were observed interacting with service users in a polite and dignified way. They were seen knocking on service user’s bedroom doors and waiting to be invited in. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 13, 14 & 15 Links with the community and family and friends are good and enrich service users’ opportunities for social interaction. The home offers choice in all aspects of the service users’ lives but this needs to be recorded more fully. The meals in the home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The home maintains a visitor’s book at the entrance to the home, which shows that the home receives numerous visitors. Staff were seen welcoming relatives to the home. There are links with the community and in particular with a local school. The home organised a Christmas party, which was well attended by relatives and friends. The home organises resident’s meetings, which are also attended by relatives. Care plans record the preferred name of the service user but do not show signatures of either service users or family and friends. Discussions with service users and staff highlighted that service users can choose where to have their meals. A survey has been carried out to determine what kind of social activities the service users would prefer. The home will need to look at recording social histories so that the background and hobbies of the more dependent service users will also be recorded and can be acted upon. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 12 An audit of the catering service was carried out in 2005 and it made several recommendations. Progress is being made to complying with the recommendations. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 16 & 18 The home has a satisfactory complaint’s system with some evidence that service users feel that their views are listened to and acted upon. Service users are protected from harm by the home’s policies and procedures. EVIDENCE: The home has a policy and procedure on responding to complaints. Since the last inspection a new method of recording has been implemented. A look at this record showed that the outcome for two complaints, reported in October 2005 have yet to have an outcome. Although this is an improvement on the previous recording, there be an outcome for each complaint or a log of action that has been taken and the reason why the matter has not been resolved. The home has an adult protection policy, which is clearly linked to local procedures. The home has reported untoward incidents and using the policy and procedure to report in the correct manner. The subject of adult protection is included in the home’s induction programme. The manager confirmed that staff have attended training however the training records are not up-to-date. A mistake was noted in the paragraph entitled “The legislation under The Care Programme Approach, which refers to The Registered Homes Act 1984, which is outdated legislation. This needs to be rectified as soon as possible. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 14 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 the following standard(s): These standards were not assessed. EVIDENCE: Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 15 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29 Progress has been made in addressing the staff vacancies so that service users will receive consistent care. There are arrangements in place for staff to have an induction. This should lead to them having a clear understanding of their role. EVIDENCE: Six of the care staff have NVQ level 2. A further four have been registered and another care assistant is coming to the end of the training course. The home is unlikely to meet the ratio of 50 of the staff trained to NVQ level 2 standards because of the reliance on agency staff to fill the high number of vacant posts. The registered providers have a “Staff Training Pathway for NVQ Awards”. There is clear evidence that new staff have had an in-house induction linked to the Skills For Care induction programme. The records show that the mandatory courses of Basic Food Hygiene, First Aid, Health and Safety and Manual handling have been completed within the first six weeks of employment. Care staff attend foundation training within 6 months of starting employment. Staff records show that new staff have had regular probation interviews to look at their progress and suitability to the role. For other staff the training records were not up-to-date and supervision records were not always available. The home has been in the process of a recruitment and selection drive to recruit to the numerous vacant posts. Discussions with the manager highlighted that employment history is checked along with identity and Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 16 eligibility to work. The process includes taking up references, CRB and POVA checks. Authenticity of qualifications and training certificates are also checked out. The whole process is designed to protect vulnerable service users. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 17 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 31, 33, 35 and 38 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. 33 & 35 In order to manage effectively, the manager needs the support of an established team of senior staff. There are systems in place for service user consultation but it takes time for service users’ views to be acted upon. There is a clear and consistent system in place to safeguard the financial interests of the service users. EVIDENCE: The manager confirmed that she is doing the Registered Manager’s Award and so is the Deputy Manager. The philosophy of care states that service users are to have a voice in all decisions affecting their care and well-being. Service user meetings are held and internal surveys are conducted for example regarding the social activities. The providers do advocate that service users and/or their relatives are involved in developing the care plans and sign to that effect. The person-in Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 18 control audits are carried out on a monthly basis and a report submitted to the home, which identifies where improvements can be made. There is a policy and procedure relating to the handling of service users’ personal monies. The records seen included date, description of expenditure, the amount spent and a running balance with two signatures to witness the transaction. The initials are generally those of the manager and the deputy. Balances were checked and found to be correct. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15 Requirement Timescale for action 31/03/06 2. OP9 13(2) 3. OP16 22 4 OP28 18(1)(a) Service user plans must be in sufficient detail to provide clear guidance to staff on the actions to be taken to meet the health, welfare and social needs. Care plans must include as much as possible the views and comments of both service users and relatives. (This requirement is being restated 23.07.05 & 10.01.06) All staff involved in the 31/03/06 administration of medication must be able to demonstrate that they have received training and have been assessed as competent to perform the role and responsibility. Complaints must be recorded in 31/03/06 the complaints log, in sufficient detail to identify that an outcome has been recorded. (This requirement is being restated 23.07.05 & 10.01.06) The training records of all staff 31/03/06 must be kept up-to-date. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP18 Good Practice Recommendations It is strongly recommended that social histories including hobbies, social pastimes are included as part of all preadmission assessments. The reference to out of date legislation in the adult protection policy should be removed as soon as possible. Compton Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 Lodge DS0000010330.V250388.R01.S.doc Version 5.1 Page 23 - 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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