Inspection on 14/12/06 for Compton Lodge

This inspection was carried out on 14th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Compton Lodge 23/08/07

Compton Lodge 10/01/06

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 14th December 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.V287298.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V287298.R01.S.doc Version 5.2 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.V287298.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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. There is a step down to bedrooms 31 & 32. 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. The range of fees for privately funded service users is from £595 to £695 according to the size of the room. For service users who are supported by public funding, the level of fees is in line with local authority pricing. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of one day by one inspector. The visit lasted a total of 7 hours from mid morning to late afternoon. The manager and the deputy was available and assisted with the inspection along with additional input from staff on duty, service users and visitors. Records such as care plans, daily logs as well accident and incident logs were examined. A tour of the building was made with attention to the rooms of the service users being case tracked. Some service users were asked for their views of the running of the home and commented on their experiences of living there. Relatives also contributed their comments. Staff were observed carrying out their duties and were involved in general discussion with the inspector. Prior to the inspection we looked at all the information we had about the home, including notifications of accidents, monthly reports about the conduct of the home sent in by the provider and previous inspection reports. A pre-inspection questionnaire had not been received prior to the inspection however ten relatives, eight service users, two general practitioners, a care manager and a health care professional returned comments cards. Their comments are reflected in this summary as well as the main body of the report. We reviewed all this information and used it to develop an inspection plan to enable us to focus on the important outcomes for service users. What the service does well: There was a lot of positive feedback about the standard of care in the home. Relatives commented “I find the staff very helpful and friendly. There is a nice atmosphere in Compton Lodge.” “I think the standard of care at Compton Lodge is wonderful. My mother is very happy there.” “My overall impression is a good one.” Prospective admissions are made to feel welcome. A service user told us “My nephew and sister came to look the home over and then my nephew brought me. All questions were fully answered.” A social worker said “The service user specifically requested this placement. Staff have been accommodating and willing to assist with dealing with any issues from food, dental care or financial management issues.” The visiting professionals supported the view that the home is well managed and that the health care needs of the service user are looked after. A GP said “A fantastically run home. I wish they were all like Compton Lodge. It could Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 6 not be better.” A relative commented “An excellent home with committed management and leadership”. What has improved since the last inspection? What they could do better: Areas where the home can improve have been discussed with the manager. Although there is an improvement in the care plans further work is required around the compiling of social histories. This information together with an audit on social activities should improve the programme available. There was a very mixed response regarding the type of social activities available in the home. Comments ranged as follows: “I would welcome more stimulation, shopping trips or the cinema.” “We are pleased with Compton Lodge. The only possible problem is that there is not enough stimulation, eg entertainments, classes etc”. “I would like an art class on a higher level.” “Usually there is activities that I can take part in like films, exercises, outings and musical events are all available” The same mixed response was received about the meals in the home. “Alternatives are available at main meals. Suppers are sometimes poor.” Or “Very little variety in the menu, with little difference between summer and winter.” “Meat is often poor quality”. However there were positive comments made about a “good chef” and “excellent meals”. The new chef is due to revise the menus and confirms that cooking methods are based on health options, therefore there should be improvement in this area. As there is now a full senior team, it is expected to see improvement in keeping training records up-to-date and in particular staff supervision. A comment from a service user was that “Carers vary. Some are very good. Some are off hand and abrupt”. Regular supervision would support both staff and managers to improve care practice where necessary. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 8 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.V287298.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have the information they need to make an informed choice about moving into the home. They are confident that the home can meet their needs. EVIDENCE: Eight service users returned pre-inspection surveys. All recorded that they had received sufficient information about the home before admission. One commented “ My nephew and sister came to look the home over and then my nephew brought me. All questions were fully answered”. A care manager commented “The service user specifically requested this placement. Staff have been accommodating and willing to assist with dealing with any issues from food, dental care or financial management issues”. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 10 The inspector was able to look at the case records of three most recent admissions to the service. Each file had a pre-admission assessment either completed by a care manager or by the manager of the care. Visits to the home had been included where this had been possible. Contracts were available for two out of the three service users. The history of the service clearly shows that all service users receive a contract, therefore we consider this standard to be met. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home still does not have records in place to show that staff are competent to administer medication. Steps need to be taken to ensure that the content and language in care plans is appropriate in order to reflect the service users’ dignity. EVIDENCE: Three care plans were examined. It is clear that improvements have been made but there is still further work required. There has been a delay in implementing a new care planning system but progress has been made. The most recent admissions all had the new format. Generally the care plans were informative as it included relationships, death and dying as well as monies and valuables. Where possible either the service user or their representative has signed the care plan. Monthly reviews are being recorded. The most salient points had been transferred from an assessment into a daily care plan. Social profiles are included as part of the care planning. These were found to be Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 12 concise and would be more effective if staff continued to develop them through their ongoing contact with service users. Please see requirement 1. It is clear from the care records and discussion with the service users that their health care needs are being met. Care records reflect the input of health care professionals such as District Nurse, Optician, Dentist, Chiropodist and visits to outpatients clinics. All service users are registered with a General Practitioner. Two returned comment cards prior to the inspection visit. They commented that staff in the home have a clear understanding of the care needs of the service users, which they are able to communicate clearly. One GP said about Compton Lodge “A fantastically run home. I wish they were all like Compton Lodge. It could not be better”. However there was a mixed response from the eight service users about the care and support they receive. Comments received were “Carers vary. Some are good. Some are off hand and abrupt.” “There is a problem in getting a bath once a week”. “There is persistent door slamming at bedtime which is a trial.” These comments were discussed with the manager and the deputy. They explained that a complaint had been made about a member of staff and this had been investigated and a resolution found. In respect of bathing, there is clear evidence that the management team have reported a problem with the hot water. The door slamming needs to be looked into especially as the inspector found that the fire doors on the corridors do shut loudly. Service users said that their privacy was respected. All the service users have single rooms. Communal bathrooms and toilets are all lockable. The core values of privacy are contained within the home’s philosophy and form part of the home’s in house induction. Both the General Practitioners, care managers, health care professional and all the relatives confirmed that they can visit service users in private. The care plans reflected both choice, independence and the preferred lifestyle of the service user however some of the language did not promote the value of dignity. There was a reference to supporting a service user with their personal hygiene to prevent them being “smelly” and refuse sacks for continence were described as nappy sacks”. This was discussed with the manager and the deputy. It was recommended that care plans were looked at during staff’s supervision sessions. Please see Recommendation 1. A requirement was made at the last inspection that all staff involved in the 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. For this reason an audit was done of the medicine trolley and medication administration records for all service users. The training records of three staff responsible for medication administration were examined. It is clear that there has been an improvement in the recording as no gaps were noted. A sample of tablets were counted and found to be accurate. However a similar issue arose at this inspection regarding the Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 13 administration of eye drops. Although the date of opening had been recorded on the outside of the container; the drops had not been discarded within 28 days as required. Staff confirmed that there is on going training in medication and the manager said that assessments of competency were done to ensure safety. However copies of these records could not be found on staff records when the manager checked them with the inspector. The printed MAR sheets supplied by the Pharmacy were not complete; because of the size of the font and the detailed description of the prescription some of the information had not been printed. The manager has been asked to speak to the supplying Pharmacist to rectify this. Please see requirement 2 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. As recorded above copies of the annual refresher were not available on staff’s training records. Medication storage was satisfactory. A Nomad system is in operation. Storage is in a cupboard and a medicine trolley. Controlled drugs are held in a padlocked metal cabinet in a locked room. There were no controlled drugs being administered at the time of the inspection. The storage and management of eye drops was questionable. Both GP’s recorded that service users’ medication is appropriately managed in the home (prescriptions and ordering). Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities programme in the home needs to be broadened to appeal to more service users. Staff in the home recognise the therapeutic value of visitors to the home and provide a welcome for friends and relatives. Service users are able to follow their preferred lifestyle. Meals in the home do not appeal to all the service users. EVIDENCE: Compton Lodge has a programme of activities however there was mixed feedback from service users and relatives as to the appeal of some of the activities. Comments received were “I would like an art class on a higher level. The present one is like a kindergarten” “There are never any activities that I can take part in, except the Garden Party”. “We are pleased with Compton Lodge. The only possible problem is that there is not enough stimulation eg entertainments, classes etc.” “Usually there are activities that I can take part in like films, exercises, outings and musical events.” Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 15 “I would welcome more stimulation, shopping trips or the cinema.” Currently the activities programme consists of a monthly reminiscence group, a monthly film, a fortnightly aromatherapy session, and a weekly art class, exercise class and communion. The programme has been expanded because of the festive season. A Christmas party and entertainments are planned. It would be appropriate if key workers compiled life histories of service users, to establish past interests, hobbies and employment and used this information to establish a broader activities programme. A survey has been carried out to determine what kind of social activities the service users would prefer. Please see requirement 3 All the relatives who returned surveys said that they were welcomed into the home. They felt that they were kept informed of important matters affecting their relatives and friends living in the home. Both relatives and health care professionals who visit the home confirmed that they were satisfied with the overall standard of care. Comments received were as follows: “I find the staff very helpful and friendly. There is a nice atmosphere at Compton Lodge” “I think the standard of care at Compton Lodge is wonderful. My mother is very happy there”. “My overall impression is a good one”. The inspector received comments from the service users regarding the level of autonomy and choice that they experienced in the home. Comments were “Staff listen and act on what I say.” “Usually staff listen and act on what I say. If the answer is no, they explain why.” The home organises resident’s meetings, to which relatives are invited. Care plans demonstrate a range of choices and include details of the preferred lifestyle pertinent to each service user. Rising and retiring times are recorded as well as preferred names. Discussions with the staff showed that they were conversant with individual likes and dislikes. Where possible care plans have been signed and agreed by either service users or their representative. Service users are able to choose their preferred meals. An audit of the catering service was carried out in 2005. Several recommendations were to be implemented however the inspector received mixed feedback about the meals in the home. Comments were as follows: “I am a vegetarian and sometimes they find it difficult to meet my wishes.” “I should have a low fat diet. This is difficult to get.” “Alternatives are always available at main meals. Supers are sometimes poor.” “I never like the meals” “There is very little variety in the menu, with little difference between summer and winter.” Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 16 “We have a good chef.” “I enjoy excellent meals” “We get good plain food but it is well done”. The service provides a cooked breakfast once a week on a Thursday. A look at the four-week menu showed that vegetarian options are available. A list of alternatives for any meal is posted on the notice board in the dining room. Discussions with the chef highlighted that menus are to be revised and this would included more interesting choices. The chef confirmed that special diets are for catered for mainly by using healthy options during the cooking process ie reduced fat, salt and sugar. From the comments made by the service users, they are not fully aware of all the options available and should be involved in the revision of the menus. The menus need to be in a more appropriate format for older people i.e bigger fonts, suitable colours and displayed more prominently. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their complaints are listened to and will be acted upon. Service users are protected from harm. EVIDENCE: The home has a complaint’s procedure. Feedback from the service users showed that they knew who to approach if they were unhappy. Comments received were: “The manager and the deputy are very approachable” “I would speak to the manager”. “Yes I Know how to complain but it is not always clear that a complaint has been noted and will be acted upon.” However one service user and six relatives responded by survey saying that they were not aware of the complaint’s procedure but had no reason to complain. Copies of the complaint’s procedure are available next to the visitor’s book although thy are not obvious. The manager of the home should ensure that the attention of the relatives is drawn to where they can locate the complaint’s procedure. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 18 A requirement had been made at the last inspection because details of the complaint, the investigation process and outcome was not being recorded in the complaints’ log. An inspection of this record showed that three complaints had been recorded and there details of action taken and the outcome. The manager has been prompt in forming CSCI about adult protection allegations. Overall the organisation has taken allegations seriously and has a proven record of taking appropriate action where required. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, and well-maintained building. The home is clean and free from odours. EVIDENCE: A comment from a service user was “The home is excellent”. A partial tour of the home was made paying particular attention to the three rooms of the service users being case tracked. The home is situated in a residential area of Swiss Cottage. It has been adapted and extended to provide residential care. It stands back from the road in mature gardens. The gardens are very attractive and tidily maintained. Every effort is made to ensure that service users are able to access the gardens and enjoy sitting in them. The home itself is accessible, safe and Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 20 well maintained. Service users said that they liked their rooms, which were seen to be personalised according to the taste of the of the occupant. Those spoken to very much appreciated the ensuite facilities. The home has a call bell system installed as well as an integrated fire alarm system, which are serviced according to contract. A service user has complained about the lack of hot water but documentation is available to show that the problem has been taken seriously and reported appropriately. Assisted toilets and bathrooms are on each floor. Throughout the inspection the home was found to be clean and hygienic. Comments from service users indicated that considered a very high standard was being achieved in this area. Cross infection policies and procedures are in place. Containers for continence wear are available. The carpet on the first floor corridor was noted to be badly marked. The manager is already aware of this and is making plans to have it clean. If there is no improvement in the appearance then a replacement will be budgeted for. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Progress has been made in addressing the shortfall of permanent staff, so that service users receive a consistent level of care. Staff receive training commensurate with their role and responsibilities in the home. EVIDENCE: The home still does not have a full complement of staff but there is less reliance on agency staff. Recruitment has also meant that there is a full senior team now in place for both day and night duty. This should ensure continuity and enable developments to take place. There are four posts still vacant, two on days and two on night duty. The vacancies has allowed the staffing hours to be rationalised to suit the needs of the home. Staff were observed going about their duties. They clearly knew the needs of the service users. Interaction was seen to be relaxed, friendly and respectful. Service users said that they were well looked after by staff. There had been a complaint from a service user about a member of the night staff. The service user had reported directly to the management and this was being dealt with. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 22 Six staff have NVQ level, one is awaiting accreditation and eight staff are currently enrolled for the same course. The manager and the deputy are awaiting their certificates for NVQ level 4. Discussions with staff and management suggested that training is available but there are still gaps in the training records, which are not an accurate reflection of the staff skills and competencies. Please see requirement 4. Recruitment and selection records have been inspected prior to the inspection. These are centrally by the provider. The recruitment files show that the provider has robust procedures in place. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of the service users with a clear and consistent system in place to safeguard the financial interests of the service users. EVIDENCE: The manager is experienced and qualified to manage the care home. Both she and the deputy have completed NVQ level 4. Following successful recruitment, there is now a full senior team so that the lines of accountability and communication should now be clearly defined. Comments from relatives were: “There is a nice atmosphere in the home” “An excellent home with committed management and leadership.” Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 24 The provider has a system of internal audits. These are carried out on a monthly basis, a report is submitted to the home and CSCI, which shows where improvements can be made. An audit has been carried out on activities and a questionnaire will be carried out in respect of the food and catering services. The service has a robust procedure relating to the handling of service users’ personal monies. Only the manager and the deputy oversees money held in safekeeping on behalf of service users. Each service users case tracked has a system in place that is compatible with their needs. One is supported by a relative, another supported through Court of Protection procedures. The arrangements that are in place are designed to safeguard the service users. The records maintained by the home allow for a clear audit trail and they are audited by the provider. Supervision records are also not up-to-date. With a full senior team, there needs to be a marked improvement by the next key inspection; especially as there has been negative comments about the attitude of the staff and for the further development of the care plans. Please see requirement 5. The home has a health and safety policy in place and staff undertake appropriate training. Records show that equipment is serviced and there is a system in place to report repairs. During a tour of the premises there were no hazards observed. Water temperatures are regulated but there is also a system in place to take random samples throughout the home. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 4 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 Service user plans need to be developed to include a detailed social history of the service user. (This requirement is being partially re-stated) All staff involved in the 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. (This requirement is being re-stated) The registered manager must speak to the supplying Pharmacist to improve the instructions printed on the MAR sheets. Service users must be consulted about their social interests and arrangements put in place so they can engage in local, social and community activities. The training records of all staff must be kept up-to-date. (This requirement is being re-stated) DS0000010330.V287298.R01.S.doc Timescale for action 31/03/07 2. OP9 13(2) 31/03/07 3. OP12 16(2)(m) 31/03/07 4. OP28 18(1)(a) 31/03/07 Compton Lodge Version 5.2 Page 27 5 OP36 18(2) Care staff must receive formal supervision at least six times a year. Supervision sessions must be recorded. 31/03/07 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 OP36 OP7 Good Practice Recommendations It is strongly recommended that care plans are discussed and the content and language reviewed at each supervision session between the key worker and the line manager. Compton Lodge DS0000010330.V287298.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V287298.R01.S.doc Version 5.2 Page 29 - 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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