Inspection on 23/08/07 for Compton Lodge

This inspection was carried out on 23rd August 2007.

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 14/12/06

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 Pippa Canter Unannounced Inspection 10:00 23 August 2007 rd 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.V333592.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.V333592.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.V333592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2007 Brief Description of the Service: Compton Lodge is a three 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 all floors 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 £630 to £730 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.V333592.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, which lasted from mid-morning until mid-afternoon, about six and a half hours in total. The manager was available and assisted the inspector along with additional input from staff on duty, visitors and people living in the care home. Records such as care plans, assessments and menus were examined. The care plans were also cross-referenced with other records, such as complaints and accident and incident reports. A partial tour of the building was made. Where possible service users were asked for their views of the running of the service and talked about their experiences of being in the home, though some were unable to give them due to their level of disability. Staff were observed fulfilling their roles and responsibilities and were involved in general discussion with the inspector. The inspector attended a handover and lunch was observed being served during one of the unaccompanied tours. Some staff were asked about aspects of care, and of their experience of working at the home. Staff recruitment, supervision, and training records were examined. Prior to the inspection we looked at all the information we had about the home, including notifications of accidents or serious incidents and previous inspection reports. The manager had not returned an Annual Quality Assurance Assessment therefore some useful information about the service was not available during the planning stages of the inspection. Surveys have been circulated but to date these have not been returned. Any feedback reflected in this summary as well as the main body of the report is direct quotes from people living in the service on the day of the inspection. We reviewed all the evidence and it has allowed us to form a judgement about the outcomes for people living in the home. At the end of the inspection, general feedback was given to the manager. A feedback form will be sent along with the draft report so the manager can let us know how she felt about the inspection process. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 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.V333592.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, as Standard 6 is not applicable to this home. - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are assessed and supported when moving into the home so that staff can meet their needs and aspirations. EVIDENCE: There is clear evidence that the home offers a planned admission process, which supports the person moving in so that they are not overwhelmed. One service user confirmed that there had been a lot of preparation attached to their admission, including visits to the home. On the day of the inspection a relative had made arrangements to look around the home and talk to the manager on behalf of her mother. Assessments are undertaken either by care management and/or by a senior member of staff from the home. Copies of assessments are available on file, Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 9 together with contracts, which show that staff receive relevant information in order to plan an individual programme of care for service users. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is continuous assessment, care planning and review which makes sure that the personal and healthcare needs of the people living in the home. EVIDENCE: A sample of four care plans were examined, which included looking at the daily recording for the previous three weeks. The care records included medical conditions, recent admissions and people with cognitive impairment. In each case we met with the person concerned but could not discuss their care with them in all cases. A comparison was made between the care recorded in the records and the care being received by each resident. A sample audit was taken of the medication administration systems. All care plans were found to be up-to-date and reflected the needs and wishes of each individual service user. The care records were comprehensive and important health and personal care needs were clearly identified. Where additional assessments were indicated, such as manual handling, risk of Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 11 pressures sores and nutritional risks, these had been carried out and were reflected in the care plans. From observation and discussion with people using the service is was clear that service delivery matched the care plans. As from previous inspections the care records clearly show referrals to and the involvement of other health care professionals. The records show that referrals are made to the Community Nursing Team and where staff have identified changes in condition or behaviour referrals have been made to the General Practitioner (GP). All service users are registered with a local GP. Entries in care records show clear evidence of collaborative care with interventions from other health and social professionals. In one instance the home has received input from the Palliative care team. Observation on the day of the site visit, discussion with staff, feedback from people using the service and the examination of the care records confirmed that staff respect the privacy and dignity of the people they look after. A requirement had been set at the last inspection for the management to be able to demonstrate that staff involved in the administration of medication their knowledge and competency. A sample audit only was taken paying particular attention to the medication administration records of the people being case tracked. The audit identified that the staff are accurately recording the receipt, administration and disposal of medication. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to follow their preferred lifestyle and can engage in opportunities for stimulation and occupation. The ethos of the home is to recognise the therapeutic value of visits from friends and family. EVIDENCE: The four care plans seen made reference to and included wishes and preferences. Staff are working to wards gathering all relevant information about the person being admitted. Discussions between and with staff identified that they clearly knew the individual preferences of the people they were looking after. Care records identified preferred names, whether gender specific care had been requested as well as preferences in respect of clothing, times of rising and retiring and bathing times. The belief systems of residents were also recorded and whether they chose to be actively involved in services or were non-practising. The care home has a reputation of making relatives and visitors feel welcome and maintaining a good level of communication with families. Relative Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 13 meetings are organised and this gives an opportunity for two-way feedback. The manager confirms that at the last relatives’ meeting, the end of life choices had been discussed. One care plan seen clearly recorded the person’s wishes not to receive active treatment, the preferred place to die and wishes in respect of scattering the ashes. Both the GP and the relative had countersigned this. This work needs to be extended for all the people living in the home. It is being approached in a sensitive way. Two requirements had been set at the last inspection for care plans to include a detailed social history and for service users to be consulted about their social interests. There has been an improvement in both areas. Care plans document social backgrounds and a programme of activities is available. People living in the home said that they have the choice to participate or not. Generally the feedback about the food was positive. Alternatives to the daily menu are available although it is unclear whether this is made clear to people living in the home. A resident commented that in his opinion “the alternative given was not substantial enough for a main meal”. The main dish was sausages and the alternative was a baked potato. This was the only negative response received. A recommendation has been made. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are fully protected by the approach to complaints, incidents and allegations EVIDENCE: Complaints, incidents and accidents are being recorded. These records were cross-referenced with the care records of the people being case tracked. The accident reports were compared with the Regulation 37 notifications sent by the service since the last inspection. The home has a comprehensive complaint’s policy and procedure. The procedure is available to people living in the home and their relatives. The service has a robust policy and procedure on adult protection, which is linked to local authority guidance. Staff have received training on adult protection and showed that they understood their role and responsibilities in this area for the safety and protection of the service users. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 15 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. People who reside in the home live in comfortable, homely and clean surroundings. EVIDENCE: The environment of this home has always been judged as being good at previous inspections. A partial tour of the home found the home to be in good decorative order, well furnished and maintained. The home provides a safe environment for people who live there and they have access to a mature well laid out garden. Overall the home was found to be clean and tidy. The home has an infection control policy. Clinical waste is stored in suitable containers and collected on a regular basis through contractual arrangements by a reputable collection agency. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 16 Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 & 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent and deployed in sufficient numbers to meet the needs of the service users. They are trained and supported to do their jobs. EVIDENCE: People living in the care home made positive comments about the staff describing them as “caring”, “always willing”, and “good at what they do.” We observed staff working with people, and generally they had warm and friendly relationships with those in their care. There was clear evidence of good practice with staff giving residents time and attention and generally being supportive. On the day of the inspection there was sufficient staff on duty to meet the assessed needs of the people living there. Discussions with staff and the manager confirmed that the organisation provides training and development opportunities for staff. However a requirement was re-stated at the previous inspection to make sure that training records for all staff were kept up-to-date. Four personnel records were looked at and it is clear that this is not happening. The personnel records did show that the service has a thorough and robust recruitment and selection process with all the appropriate checks in place. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 18 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): 31, 33, 35, 36 & 38 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 managed in the best interests of the people who live there. EVIDENCE: Discussions with the manager during the site visit demonstrated a good level of awareness of the strengths of the service and the areas where improvements are necessary. There are clear lines of accountability and communication within the service. The judgements in preceding sections of this report have contributed to the judgement in this outcome area. The care home has a welcoming environment and promotes an open and transparent style of management. The company invests in the continuing developing of the staff team however Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 19 this cannot be demonstrated by the training records as previously identified. A requirement was made at the previous inspection that care staff must receive formal supervision at least six times a year, with supervision sessions being recorded. The requirement is being re-stated as the personnel records did not demonstrate that this was happening. A sample of health and safety records were looked at. These confirmed that the home is being managed responsibly with essential checks being made. The provider monitors health and safety in the home. There are robust procedures in place to monitor compliance. Equipment is serviced regularly and where required repaired or replaced. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 20 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 3 X X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 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.V333592.R01.S.doc Version 5.2 Page 21 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 OP28 Regulation 18(1)(a) Requirement The training records of all staff must be kept up-to-date. (This requirement is being re-stated from the inspection 10th January 2006 and 13th December 2007) Care staff must receive formal supervision at least six times a year. Supervision sessions must be recorded. (This requirement is being re-stated from the inspection 13th December 2007) Timescale for action 31/12/07 2. OP36 18(2) 31/12/07 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 OP15 Good Practice Recommendations It is strongly recommended that staff discuss in detail any alternatives that are available to the main meal with residents. Compton Lodge DS0000010330.V333592.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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.V333592.R01.S.doc Version 5.2 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. 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