Inspection on 28/06/07 for Compton Manor

This inspection was carried out on 28th June 2007.

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 Manor 07/11/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Compton Manor Compton Road Holbrooks Coventry West Midlands CV6 6NT Lead Inspector Patricia Flanaghan Unannounced Inspection 28th June & 2nd July 2007 08:30 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 Manor DS0000067096.V343924.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 Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Compton Manor Address Compton Road Holbrooks Coventry West Midlands CV6 6NT 02476 688338 02476 688338 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) Mr Vijay Odedra vacant post Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Compton Manor is a care home for thirty older people, situated in the Holbrooks area of Coventry. Accommodation is located on the ground floor and first floor. There are 22 single bedrooms and 4 shared bedrooms with 5 of the single bedrooms having en-suite facilities. The first floor is accessible by a passenger lift. The home has a lounge and separate dining room on the ground floor with a small sitting room on the first floor. There are open plan gardens to the front and private gardens to the side. There is a regular bus service, which passes the home, to enable ease of access to local shops and the City Centre. Compton Manor is registered to provide care and accommodation for older people assessed as not requiring either specialist dementia care or nursing care. At the time of the inspection visit the fees charged for a place in the home were £336.00 per week. Additional charges are made for hairdressing and chiropody. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for residents and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This was a key unannounced inspection visit, which addresses all essential aspects of operating a care home. This type of inspection seeks to establish evidence showing continued safety and positive outcomes for residents. The visit to Compton Manor was carried out by two inspectors and took place on Thursday 28th June 2007, commencing at 08:30am and concluding at 07:30pm. A further visit was made on 1st July 2007 to examine some policies and procedures relating to the running of the home. Since the last key inspection in November 2006 a random inspection was undertaken in February 2007 to look at compliance with requirements set at that inspection. Evidence of some improvement was found during the random inspection. This key inspection visit showed some improvements in a number of key areas and it was evident that the manager is making good progress in ensuring Compton Manor is meeting regulations and national minimum standards of practice. Before the inspection the manager of the home was asked to complete and return a questionnaire containing further information about the home as part of the inspection process. Some of the information received within this document has been used in assessing compliance with standards and is included within this report where appropriate. Before the inspection, a random selection of people who live in the home and relatives were sent questionnaires to seek their independent views about the home. No written comments were received from people who use the service or from visitors to the home, at the time of writing this report. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 6 Three people living at the home were identified for close examination by reading their, care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ and where evidence of the care provided is matched to outcomes for residents. Records examined during this inspection, in addition to care records, included, staff recruitment records, training records, social activity records, staff duty rotas, health and safety records and medication records. The home’s manager was present throughout the day and the inspector was able to tour the home, and spend time speaking with residents and staff. The inspector had the opportunity to meet a number of the residents by visiting them in their rooms and spending time in communal lounges and dining areas and talked to several of them about their experience of the home. The home had not recorded any complaints since the last key inspection in November 2006. Two complaints had been received by us which were looked into at this visit. Issues raised were lack of food in the home, with no money available to buy more. These issues were looked into and are detailed under the corresponding outcome areas. No regulations were found to have been breached when looking into these issues. What the service does well: All of the people involved in this inspection were positive about the staff and their caring attitudes to the people using the service. Comment received include: • • “They look after me very well” “the staff are all kind and friendly” The menus were varied and nutritious and offered choices at each meal. The meals for the day were put on a menu board in the dining room. Residents spoken with were satisfied with the food being served to them. Visiting is flexible and takes into account the needs and expressed wishes of the people who live in the home. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 7 People moving into the home are able to bring personal possessions with them as was demonstrated when viewing bedrooms. Such items as photos, pictures, plants and small pieces of furniture were in evidence. What has improved since the last inspection? The home has addressed many of the requirements made at the previous inspection. This indicates the continued ongoing improvements that are being made for those people who live there. A considerable improvement has been made since the last inspection, in the quality of pre admission assessments. Assessments read were clear and contained a good level of information and covered the areas identified by the National Minimum Care standards. Improvement has also been made across the home in respect of their care planning systems. Care plans are now well organised, information can be located easily, and risk assessments are in place although the manager agreed that there was more to be done to make the care plans more focused on individual needs, particularly in care plans of residents who have been in the home for some time. Since the last inspection two outside entertainers have been included within the activities programme, one to promote progressive mobility and the other for a reminiscence session. The manager is collecting a wider range of information about the home for prospective residents and their representatives to view to assist them in making decisions about the services provided. The service User’s Guide has been updated and copies were available for residents and anyone enquiring about the home. The new manager has developed an appropriate complaints procedure and this was seen on the second day of the inspection visit on display in the reception area. Training courses for staff have improved since the last inspection and a record of all training is now maintained. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 8 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 Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 9 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 Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 10 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. The home does not provide intermediate care. Quality in this outcome area is good. The home undertakes pre admission assessments prior to accepting a new resident for admission to the home. Assessments are thorough and provide the home with sufficient information to assure prospective residents that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre admission assessments for two residents recently admitted to the home were read. The new manager has changed the documentation used to undertake this assessment, to include more detailed prompts for staff undertaking the assessment, rather than broader headlines. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 11 Examples for both systems were read. Assessments seen were clear and contained a good level of information and covered the areas identified by the National Minimum Care standards. That is diet and nutrition, mobility and falls history, continence, personal care including foot, oral and eye care, health care and hobbies and interests. Risks areas were also identified. This constitutes a considerable improvement since the last inspection, when assessments were not being consistently undertaken and the home could not demonstrate that they could meet the needs of people referred to the home. Of the two examples read, the old version allowed more space for information to be recorded, and also recorded the actions taken as a result of the assessment. A discussion was held with the new manager about the benefits of combining the two documents to reflect best practice from both. The home should also include how the prospective resident and/or their representative was involved in the assessment and how their personal circumstances, worries and concerns about moving into residential care, were being addressed and understood by the staff. One of the assessments was for a resident only admitted to the home two days before the inspection, and therefore a care plan was not fully in place, although some risk assessments had been undertaken. The manager must ensure that a care plan is in place to cover the first 24 hour period, so that the staff are fully aware of the care required, prior to a full care plan being available. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 12 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 and 10. Quality in this outcome area is adequate. Care planning generally has improved across the home, to reflect the personal and health needs of residents and the actions required by staff to meet those individuals’ needs. Systems for safe administration of medications are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for four residents currently living in the home were read as part of this inspection. Two of the residents were new to the home, whilst two had been living there for some time. It is commendable to note that some considerable improvement has been made across the home in respect of their planning systems. Care plans are now well organised, information can be located easily, and risk assessments are in place. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 13 This has been a great deal of work undertaken by recent management teams and the staff in the home and this has generally brought documentation up to an acceptable standard. In the process of updating all these care plans, and auditing the information contained including the inclusion of contracts and other paperwork, some of the information is brief. The manager agreed that there was more to be done to make the care plans more focused on individual needs and to add more detail in some areas, particularly in care plans of residents who have been in the home for some time. Examples of this are particularly in regard to nutrition. The care plan for one very frail resident who was assessed as being at high risk, did not accurately reflect what staff are now doing to meet identified needs. The weight chart was not accurately completed, leading to confusing results. Care plans to reflect how residents social and recreational needs also lack detail, and generalised statements are made. For example: ‘Encourage ……. to take part in social interaction and prevent isolation’. This needs to be developed to ensure that it is linked to personal likes and dislikes, and identifies how this will be achieved either by the home’s own internal activities programme, or using external resources. As the care plans are all newly in place, it was not possible to assess the regularity of a review process, but there was evidence that reviews had taken place with social workers. There was also evidence that information identified on the initial assessment was transferred in to the care plan and followed up. One example of this was a need for some chiropody. This was entered into the care plan and a record made of when a visit was undertaken which was four days following admission. Daily records completed by care staff lack sufficient detail to accurately reflect how someone has spent their day, and do not always follow up on concerns raised. Daily records routinely record that someone has ‘ate well’ slept well’ were ‘sitting outside’ ‘up and dressed’. One morning shift entry made stated: ‘ ……. was a bit upset this morning but has calmed down now’. There was nothing to say why he was upset, what actions staff took or what staff coming Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 14 on to a shift may have needed to observe. The afternoon shift had simply recorded ‘no problems’. The medication for the four residents whose care plans were read were looked at to see if the home has continued with the improvements recently made and identified by visits from our pharmacy inspector. The medication trolley was found to be neat and tidy, so that medications could be easily identified. The Medication Administration Records (MAR) charts seen were well completed with no omissions. Photographs are available to minimise the risk of wrongful administration. Systems for the administration of controlled drugs are robust. Staff spoken with demonstrated a good and positive attitude toward medication processes, and had received recent training. During the inspection residents were treated respectfully and there was a good level of interaction between staff and residents with staff demonstrating a good understanding of their needs. All residents seen were appropriately dressed, clean and tidy and staff spoke respectfully to them. The pay phone previously used by residents has been removed. On the day of the visit the portable hand phone was out of order, so that people needing to make or receive a personal call would have to use the main phone in the office which would mean a lack of complete privacy. The manager said that she was waiting for a new handset for the phone to be ordered by the registered provider. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 15 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 and 15 Quality in this outcome area is adequate. There are limited activities available within the home and not all people who use the service have their recreational needs met. Residents are offered a choice of meals, which meet any dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was difficult to determine if the social needs of the people living in the home were being met, as there were little or no care plans detailing what peoples’ interests or hobbies were. As indicated previously in this report, the manager is in the process of reviewing care plans for all the people who use this service. There needs to be some consultation with the people living in the home about the range of activities available to them and arrangements made to ensure their individual social needs were met. The manager said she was organising an activity programme and some external entertainment is being arranged to ensure that residents were stimulated. For example, in house activities offered included videos, dominoes, bingo, sing a longs. Since the last inspection two outside Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 16 entertainers have been included within the activities programme, one to promote progressive mobility and the other for a monthly reminiscence session. The manager said that residents have enjoyed a musical concert and a theatrical play in the home in the past month. A bingo session was held in the afternoon during in the inspection visit, but only four people participated. The television in the main lounge had a poor picture quality, which detracted from residents’ enjoyment of any television programmes people may have been watching. The manager said that a new television was being purchased with money from the “residents funds account.” A person spoken with said they did nothing during the day, “just sat.” Another stated they got bored because staff did not take them out although they went out occasionally with family. There was no evidence of any trips outside of the home, apart from one, which was organised by the person before admission to the home. It is recommended that activities are discussed with the people living in the home, collectively and individually, to ensure their expectations are met. There did not appear to be any restrictions on visitors to the home within reasonable hours. Friendly relationships between staff and visitors were evident. A visitor spoken with at the time of the visit was happy with the service being offered to their relative and confirmed they were always made welcome by staff. People living in the home were able to make choices on a daily basis, for example, when to get up and go to bed, what to wear and what to eat and how to spend their time. It is recommended that care plans include more detail of the preferred daily routines of the residents, their likes and dislikes and if they are able to make choices particularly where residents have some confusion so that staff were aware of these preferences. People were encouraged to personalise their rooms to their liking and personal possessions were observed in the rooms seen. When the inspector arrived at 8.30am people who use the service were preparing to have breakfast, some were seated at tables while others were still arriving, or being assisted into the dining room. People were given a cup of tea on arrival in the dining room, but none of the residents received breakfast until everyone was in the room. Some people had to wait up to 45 minutes for breakfast to be served. The manager should review staffing arrangements in Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 17 the morning to ensure an adequate number of staff are available which would mean people receive their breakfast in a timely manner. The meals for the day were put on a menu board in the dining room. One person was observed to be laying the tables in preparation for lunch. Three choices of hot meal are available and further alternatives are available if the residents do not want what is on the menu for that day. Snacks are available throughout the day. The home is able to cater for special diets for reasons of cultural or medical needs. As there are a large number of residents of Asian origin in the home, there is always an alternative of a curry normally vegetarian with rice and a chapatti. People spoken with were satisfied with the food being served to them. One person said, “the food is good, we get plenty to eat.” There had been a recent complaint lodged with us which included an issue about the lack of food in the home, with staff having to use their own money to purchase more. Food stocks at the time of the visit were adequate. The registered provider stated that there was always petty cash in the home to purchase extra supplies, but the manager said that this was not always the case. The registered provider undertook to ensure there is always a sufficient balance in the petty cash account to ensure staff do not have to use their own money to purchase essential items. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 18 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 and 18 Quality in this outcome area is good. Residents have access to the information they need to complain and can be confident that staff members are trained and understand how to recognise and respond to any allegations of potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about how to complain is displayed in the home and is referred to in the Service User Guide, which has recently been developed by the new manager. A number of residents spoken to were not aware of a complaints procedure but would complain if they were unhappy with the service. None of the people spoken with had made a complaint. Comments received included: • • “I’ve no need to complain” “I haven’t needed to make a complaint, but I would talk to one of the staff” The home has an adult protection written policy and a whistle blowing procedure to encourage staff to report any concerns in respect of abuse. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 19 The home has acted appropriately and effectively dealt with an issue regarding a member of staff who no longer works for the organisation. Staff spoken with were able to demonstrate that they would respond appropriately if abuse is suspected. The majority of staff have recently had training in abuse and the Protection Of Vulnerable Adults (POVA) and this should ensure that staff have the knowledge to safeguard residents from harm if an allegation should arise. The manager has also arranged training for the remainder of staff. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 20 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): 19, 24 and 26 Quality in this outcome area is adequate. Some areas of the home are in need of attention so that people living at the home enjoy the same comfort, safety and homeliness provided in the rest of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has commenced some minor refurbishment. Laminate flooring has been laid throughout the downstairs corridor areas. Several bedrooms have been painted and laminate flooring also laid to enhance their appearance. The majority of bedrooms have been personalised to reflect the resident’s personality, and people spoken with stated that they were happy with their bedroom. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 21 All bedrooms have a call bell system to enable assistance to be summoned when required and double rooms have curtains between beds to provide privacy. Some of the linen was found to be worn/damaged and some pillows were thin/lumpy. All linen, pillows and mattresses must be reviewed and replaced where necessary to ensure residents comfort. Bed bases were worn in a number of bedrooms; the manager advised that she had ordered five new bed bases, which would be delivered in July. Two bedrooms contained camp bed style beds with tubular frames. This type of bed is not homely and is unsuitable for use by elderly people. The manager undertook to raise this matter with the registered provider and ensure these are replaced as soon as possible. Bedrooms visited had some furniture in poor condition. A towel rail was coming off the wall and two vanity units seen looked old and in need of repair or replacement. The corridors on the top floor were in need of redecoration. Since the last inspection a lock has been fitted to one of the bedroom doors to enhance privacy. The external appearance of the home is looking shabby with peeling paintwork on windows and is in need of maintenance work. One of the bathrooms has been converted to a walk-in shower which the manager advised is very popular with the residents. The door to the shower room was missing and the manager said she was waiting for the home’s maintenance person to re-hang it. In the meantime, people were not able to avail of the shower. The home was clean and generally odour free on the day of the visit, this ensures that a comfortable and homely environment is provided for people who live at the home. Two bedrooms had offensive odours present at the time of the visit and this is not pleasant for the resident or relatives and friends who visit. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 22 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 and 30 Quality in this outcome area is adequate. There are sufficient numbers of staff on duty to meet the needs of people living in the home but the failure to maintain robust pre employment checks and mandatory training for staff puts people at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty records were examined during the inspection and these showed that the home was providing adequate numbers of staff for the number of people being accommodated at that time. At the time of this inspection visit, the inspector was informed there were 24 people accommodated at the home. Staff spoken with confirmed that the staffing levels were about right for the number of residents. The personnel files of three staff members were inspected. There have been no new staff members employed since the current manager was appointed in May 2007. Records of staff employment remain poor and did not give the detail required to show a robust employment procedure. References were not dated, were not clear about who was giving the reference and were not checked as to their validity. In two cases there was only one reference evident. There was no record of an interview or discussions about gaps in Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 23 work history being explored. Criminal Records Bureau (CRB) disclosures were evident on all files. The new manager is reviewing all the staff files and is aware of the improvements necessary to safeguard people who live in the home. Information supplied on the pre-inspection questionnaire completed by the deputy manager indicates that 10 of the 19 staff employed at the home have a National Vocational Qualification (NVQ) at Level 2 in Health and Social Care. The manager said that a further two staff have been enrolled on an NVQ training course. The manager is reviewing the training records and has developed a training matrix which clearly details training undertaken by staff and also their training needs. Evidence was seen of recent training undertaken and included moving and handling, Diabetes awareness, oral healthcare, Safeguarding Adults and First Aid. Seventeen staff have been enrolled on Infection Control distance learning course through a local college. Staff who do not have current Moving and Handling and Fire Safety training need to be updated to make sure the safety of people in the home is protected. People who use the service consider the staff kind and helpful. People said: • • • “the staff are all kind and friendly” “the manager and staff are all wonderful” “The girls are marvellous, always smiling” Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 24 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 and 38 Quality in this outcome area is adequate. New management arrangements, demonstrate that the home is well managed and has effective leadership, giving assurance that the health and safety of people who live at the home will be safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a new manager since May 2007 having been without a permanent manager since August 2006. She has over three years experience in managing older peoples’ homes. She was observed giving appropriate guidance and support to both residents and staff. Staff provided positive feedback about the way the home is managed. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 25 At the time of writing the report, we had not received an application from the owners for the person employed as manager to be registered. The owners must take action to ensure an application is submitted so that we can be sure an experienced and qualified person is managing the care home. Secure facilities are available for the safe keeping of residents’ personal money and valuables. Written records are available for all transactions and detail the reason for the withdrawal and two signatures. People are able to control their own finances if they want to and are able to, but the majority of services users have their finances managed by their families or by advocates. The staff spoken with during the inspection stated that staff worked well as a team and that there were no issues with the management of the home. There had been no improvements in relation to quality monitoring in the home since the last inspection. A quality monitoring system has been developed for the home, but the audits including questionnaires seeking the views of people who use the service, had not been completed at the time of the inspection. The acting manager was aware that the home needed a formal quality assurance system based on seeking the views of the people living in the home with a view to improving the service on offer. The manager said that she had arranged a residents/relatives meeting shortly after she took up her post. Unfortunately, nobody attended and she said she is arranging a further meeting in the next few weeks. The manager is aware that these meetings to give residents and their relatives an opportunity to be involved in the way services are provided. As raised in previous inspections, the responsible individual has not been completing monthly unannounced visits and supplying the manager with written reports of his findings. The manager was carrying out formal staff supervision and notes to these meetings were seen in staff files. Information provided by the home shows that the home has undertaken the required safety checks related to electrical and gas installations, portable appliances, hoists and other equipment, and water tests for temperature control and Legionella. A record is maintained in the home of any accident or incident that happens to person using the service. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 26 The home’s programme of mandatory training further protects the safety of people in the home but staff who do not have current Moving and Handling and Fire Safety training need to be updated to make sure this is consistent. The fire officer had inspected in the home on 04/06/07 and had made a number of requirements in respect of fire safety. A further visit will be made to the home in December 2007 to ensure compliance with these requirements. During discussions people told the inspector that the home had recently had a number of electrical power cuts. The manager confirmed that this had happened on a number of occasions and an electrician had identified an electrical fault. The manager said she was waiting for the registered provider to authorise the repair work. This should be done as soon as possible to ensure the safety and well being of people living in the home. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 27 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 1 Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 28 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 Care plans must reflect all the care needs of the residents and give clear and concise guidance to the staff. A care plan covering risk areas must be in place following admission to cover the first 24 hour period, so that the staff are fully aware of the care required, prior to a full care plan being available. This will ensure that people receive person centred support that meets their needs. Daily records including night care, require development to ensure that they are sufficiently detailed to accurately report changes and incidents so that staff are fully informed. This will ensure that the home can be sure all people using the service have their needs met. Risk assessments undertaken following assessment and care plan review, must clearly and accurately describe the actions to be taken by staff to minimise the risk and must be regularly monitored and changes recorded. This is particularly DS0000067096.V343924.R01.S.doc Timescale for action 30/09/07 2. OP7 17 30/09/07 3. OP8 12,13 30/09/07 Compton Manor Version 5.2 Page 29 important for nutritional needs. This means the home can be sure residents’ health, safety and welfare is being promoted and maintained. Suitable beds and bed linen to 31/08/07 meet the needs of the people who use this service must to supplied ensuring their comfort and care. Full and satisfactory information 31/07/07 on all employees must be obtained prior to employment. This must include professional references from previous employers in care, exploration of gaps in employment and evidence of qualifications. This will ensure that people who use the service have their health safety and welfare protected. Previous timescale of 30/09/06, 31/12/07 and 30/04/07 not met. Arrangements must be made for all staff to have up to date mandatory training in Fire Safety and Manual Handling. 4 OP24 16 5 OP29 19 Sch 2 6 OP30 18 30/09/07 7 OP31 9 8 OP33 24 This is to ensure that people in the home are protected from the risk of harm. An application to register the 30/09/07 manager with us should be submitted. This will ensure that residents can be confident that someone who is appropriately qualified and experienced is managing the home. A suitable quality assurance and 30/09/07 monitoring systems must be in place, actions planned must be completed in a timely manner and reports available for inspection. This will show how people are being consulted about DS0000067096.V343924.R01.S.doc Version 5.2 Page 30 Compton Manor 9 OP38 13, 18 the running of the home and that it is being run in their best interests. Previous timescale of 30/09/06 and 30/04/07 not met. The standards of health and 31/08/07 safety management within the home must be reviewed. This should include the electrical safety and the fire safety requirements. This will ensure that people who use the services have their health safety and welfare protected. 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 OP7 Good Practice Recommendations Care Plans should include more detail of the preferred daily routines, likes and dislikes, how choices are made, particularly where residents have some confusion so that staff were aware of these preferences. This will ensure that person centred care is being provided. The manager should consult with the people living in the home about the range of activities available to them and arrangements made to ensure their individual social needs are met. The support needs of residents at breakfast should be assessed and the outcome used to ensure sufficient numbers of staff are available to meet the needs of residents. This will ensure people receive their breakfast in a timely manner. A maintenance plan is to be devised with dates to address those areas needing attention, for example, worn carpeting, shabby wallpaper on corridors, chipped paintwork to stairs, door frames and skirting boards. This will ensure that people who use this service live in clean and pleasing surroundings. An audit of all linen, pillows and mattresses must be undertaken and items replaced that are worn/damaged to DS0000067096.V343924.R01.S.doc Version 5.2 Page 31 2 OP12 3 OP15 4 OP19 5 OP24 Compton Manor 6 7 OP26 OP33 ensure residents comfort when in bed. Residents surrounding should not have any offensive odour. This is to ensure that they are living in comfortable and hygienic surroundings. The responsible individual needs to conduct unannounced monthly visits and supply a written report to the manager. This means the responsible individual is able to form an opinion of, and monitor the standard of care provided at the home. Compton Manor DS0000067096.V343924.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 - 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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