Inspection on 23/07/05 for Compton Lodge

This inspection was carried out on 23rd July 2005.

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 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 14/12/06

Compton Lodge 10/01/06

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 Treadwell-Smith Unannounced 23 July 2005 09.00 am rd 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 Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Compton Lodge Address 7 Harley Road, London, NW3 3BX 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) 020 7722 1280 0207 586 8113 eileen.salem@ccht.org.uk Central and Cecil Housing Eileen (aka Ellen) Salem Care Home 34 Category(ies) of OP old age registration, with number of places Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No conditions Date of last inspection 17th February 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 G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one Saturday morning in July and lasted about 4 hours. The manager was available and assisted with the inspection. A partial tour of the home was made and about 5 service users were spoken to. The inspector attended a handover and had a general discussion with about five staff members. A variety of records, including care plans, menus, complaints, training records and health and safety documents were looked at. What the service does well: What has improved since the last inspection? What they could do better: Areas in which the home could be doing better were discussed and agreed with the manager. More attention needs to be paid to the content of the care plan so that it is a “live” and effective document. Service users, especially those with more specialised needs, would benefit from a wider range of social and daytime activities. There needs to be a better recording of the investigation and outcome of complaints. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 only as Standard 6 is not applicable to this home as it does not provide intermediate care. Prior to people moving into the home an assessment is completed however this is not always an assurance that the person’s wishes and care needs will be met. EVIDENCE: Five of the service users were spoken to. Most said that they enjoyed living in the home and felt that their needs were being met. One thank you card said “ Thank you all for your wonderful care of me”. A few felt that their expectations were not being realised. Service users and their relatives are always invited to visit the home prior to admission. One service user had visited the home and felt that the home was the right place for her. Four case files were checked and all had an assessment either completed by a care manager or by the management of the home. Although the assessments covered social needs these had not always been transferred in sufficient detail into a care plan. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 standard(s) 7 & 8 A clear and consistent care planning system has yet to be introduced that adequately reflects the wishes and needs of the service users. Staff do not always record the relevant information to ensure that health needs are satisfactorily met. This shortfall may have a potential to place service users at risk. EVIDENCE: Four care records were checked. Each one had a care plan but these were noted not to be up-to-date and therefore not contain accurate information. One service user had been assessed as having a high risk in respect of tissue viability. The care plan had not been updated with the need for pressure area care. Another care plan did not identify that a service user require light, frequent meals. All care plans had only sparse information relating to social histories, hobbies and preferred activities. Discussion at the handover suggested that these needs were being addressed even though there was alack of clear plans and guidance. This approach is dependent on staff memory and good verbal communication systems. If these informal systems break down then service users are potentially placed at risk. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 10 A trawl through the care records and discussions with service users and staff identified that health acre needs are being addressed. All the service users have a General Practitioner. The District Nurse attends to some of the service users and there is evidence of referrals to outpatients’ clinics. Service users also receive a chiropody service. Specialist equipment such as pressure relieving mattress, cushion and wheelchair have also been requested for one service user. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 standard(s) 12 &15 Service users, especially those with more specialised needs, do not benefit as they might from a sufficiently varied and stimulating range of activities and outings. The meals are managed well and provide daily variation for people living in the home. EVIDENCE: Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 12 All service users are able to have access to radio, television and newspapers and magazines. A library service regularly attends. The statement of purpose gives an account of the arrangements users to engage in social for service activities, hobbies and interests. A similar programme of activities and events is on display in the home as previously seen at the last inspection. This does not always reflect the diversity of the service users and their social, cultural, intellectual and physical capabilities. An inspection of the care records showed that social histories and are not always documented on admission. Although the assessment may take into account social activities, hobbies and pastimes, these are not usually reflected in the care plans. The home needs to provide a more extensive programme to ensure all service users have a sufficiently stimulating and varied choice of activities. The catering service has been subject to a recent audit. This has highlighted that menus need to be available on each dining table, in varying formats suitable for use by service users and in particular in large print. The menu on display shows that choice and variety is available. Apart from the main meal there is a vegetarian option and an alternative available. Specials diets are catered for. There is a lack of space in the dining room for all service users to be seated comfortably and receive assistance if required. Service users have the choice of having breakfast in their rooms. Service users who require assistance with eating and drinking sit together in the conservatory. The service users said that they enjoyed the food. They are able to give feedback about the quality and variety of the meals at the “Resident’s Meeting”. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 standard(s) 16 The home has a complaint’s system but the recording is poor therefore it is not possible to determine whether complaints are handled objectively. EVIDENCE: The home has policies and procedures in place in relation to reporting and investigating complaints. The home has a complaint’s procedure and this is made known to service users through the “Guide”. The CSCI has received two complaints about the home. One was looked at using the inspection process and the second is being managed with the involvement of Camden Social Services. There is a log kept of complaints. It showed that 4 complaints were logged in 2003 but only one was documented. It related to the insensitive and uncaring treatment by a care assistant. Although the service user was spoken to, no investigation or outcome has been recorded. A further complaint has been logged for 14th February 2005. The most recent complaint has not been documented. The manager is known to talk to service users about concerns but there is a reliance on anecdotal evidence. This is not always sufficient to ensure that service users feel that their concerns are taken seriously. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 standard(s) 19 & 26 The service users of Compton Lodge live in an attractive and comfortable environment with a good standard of cleanliness and hygiene. EVIDENCE: The home is situated in a residential area of Swiss Cottage. 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. One service user said, “I particularly enjoy the garden and sit out most afternoons”. The home itself is accessible, safe and well maintained. Service users said that they liked their rooms, which they are able to personalise them with their own belongings. Those spoken to very much appreciated the ensuite facilities. 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. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 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 & 30 Some progress is being made in recruiting staff to vacant posts. It is not possible to address developments in the home until a full permanent team is in place. Staff are able to achieve the essential skills and training to meet the needs of the service users. EVIDENCE: Residents spoken to said that the staff at the home were kind and caring but it was evident that they are very busy. On the day of the inspection the manager arrived in response to being one staff member short due to illness. The inspections in July 2004 and February 2005 identified that the home was experiencing a recruiting dilemma especially in respect of senior care staff. The staff team on duty on the day of this inspection consisted of agency, bank and a couple of permanent staff. This makes it difficult to allocate a key worker to each service user. Staff confirmed that on each shift they are allocated so many service users to look after but with the advent of agency staff and bank workers this may or may not mean that the member of staff is able to fulfil the role of a key worker. The manager confirmed that staff have been chosen but because of the robust recruitment and selection processes, there is a delay in starting. Training records show that staff have done training in essential areas, such as first aid, basic food hygiene, medication, manual handling and general health and safety. Some staff are undertaking NVQ Level 2 to improve their caring skills further. Three staff are started upon the TOPPS induction. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 16 Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 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 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) 38 The health safety and welfare of service users are being promoted. EVIDENCE: A wide range of records were looked at, including fire safety and accident reports. The records were detailed and accurate and confirmed that the home is being run responsibly with essential checks being made and acted upon. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 18 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x 3 Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement 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 re-stated) A wider range of stimylating activities to be available for service users. (This requirement is being re-stated) Complaints must be recorded in the complaints log, in sufficent detail to\ identify that action has been taken and th eservice userr notified of the outcome. Timescale for action 31/10/05 2. 12 16 31/10/05 3. 16 22 31/10/05 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 3 Good Practice Recommendations It is strongly recommended that social histories including hobbies, social pastimes are included as part of all preG58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 20 Compton Lodge 2. 15 admission assessments. The recommendations of the internal catering audit should be implemented as soon as possible. Compton Lodge G58 s10330 Compton v210274 230705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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. 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