Inspection on 07/11/06 for Compton Manor

This inspection was carried out on 7th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 28/06/07

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 Key Unannounced Inspection 7th November 2006 09:20 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 Manor DS0000067096.V319348.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.V319348.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 Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 April 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.V319348.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 the Commission for Social Care Inspection (CSCI) 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 unannounced inspection, carried out by two inspectors, took place over one day on Tuesday 7th November between 9:20am and 6.45pm. A separate visit made by a pharmacist inspector to look at the management of medication, took place on Tuesday 14th November 2006. Three residents were ‘case tracked’. This involves establishing an individual’s experience of living in the care home by meeting or observing them, discussing their care with staff, looking at their care files, and focusing on outcomes. Inspectors had the opportunity to meet some of the residents and talked to three of them about their experience of the home. The residents were able to express their opinion of the service they received. General conversation was held with other residents along with observation of working practices and staff interaction with residents. Conversations were also held with two visitors and a visiting social worker about their experience of the home. An inspection of the environment was undertaken, and records were sampled, including staff training, health and safety, rotas, complaints and fire records. Since the last key inspection on 18th April 2006, we have received one allegation of abuse. The allegation of abuse was referred to social services for investigation, in accordance with the local arrangements for the protection of vulnerable adults. No further action was taken, following an investigation into the allegation The outcome of random inspection visits on 15, 16 and 31 August 2006 to assess outcomes for residents in respect of three shortfalls identified during the last full inspection failed to identify the improvements necessary to achieve a positive outcome for residents. As a consequence, a statutory enforcement notice was issued in respect of medicine management to bring about the improvements necessary to ensure positive outcomes for residents. The Registered Provider failed to provide appropriate staff training in a number of key areas or to update all resident records to ensure assessments and written resident plans accurately reflect their current care needs. Rigorous staff recruitment procedures were not in place so we couldnt be sure residents Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 6 were safe. The medicine management remained poor and in some instances had the potential to place residents at high risk. What the service does well: What has improved since the last inspection? What they could do better: As identified at the last inspection the systems for care planning and risk assessments in the home still needs to be improved to ensure the residents needs were identified and staff knew how to meet them and that any risks were minimised. There needs to be a system in place to ensure health care needs are monitored on an ongoing basis. The registered provider must ensure that a full and comprehensive assessment prior to admission and ongoing after admission is completed to establish the care needs of the residents. The registered provider needs to ensure that staff are aware of any instructions written for them to follow and that they know what the instructions meant. Following a Statutory Requirement Notice served due to the poor management of medicines in the home the service has failed to improve to a satisfactory manner. The range of activities available for the residents must to be explored with them to ensure they met the social needs of the residents. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 7 To ensure the residents were aware of their rights in relation to making complaints they must be issued with a copy of a satisfactory complaints procedure. The privacy and dignity of residents must be maintained at all times The registered provider must ensure that induction and health and safety training, including infection control, is provided and regular updates available to the staff to ensure they are suitably trained for their individual roles. Recruitment procedures in the home must be reviewed to ensure a robust and consistent approach to staff recruitment and employment practices. A Statutory Requirement Notice has been served on the registered provider in relation to this matter. The staff training matrix must continue to be reviewed and updated with particular emphasis in the mandatory areas of fire safety, first aid, moving and handling, food hygiene and infection control. 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.V319348.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6 Quality in this outcome area is poor. The home is unable to demonstrate that pre admission assessments are undertaken and therefore that the home can meet the needs of prospective residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of three permanent residents in the home, and one admitted on an emergency placement were read during the inspection. There was no evidence on any of the files read that a pre admission assessment had been undertaken and / or the results of that assessment had been recorded. The home does not currently formally inform prospective residents or their families, that they can meet the needs of a prospective resident. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 10 Discussions held with staff indicate that assessments are undertaken and that copies of the social services care management assessment is received and used as part of the assessment process. The care file of the resident admitted as an emergency did contain a copy of the social services assessment. The lack of a recorded needs assessment, does not allow the home to demonstrate what needs have been identified, and how the home intends to meet those needs. This is of particular concern where a prospective resident has specialist needs, for example a sensory impairment or a particular physical disability. On the day of the inspection it was noted that residents in the home have a variety of specialist needs including memory impairment and physical conditions such as diabetes. The home must be able to demonstrate that staff have the required skills and experience to meet those assessed needs. The home has developed a ‘Needs led assessment’ tool, which if completed fully would meet the standards required. The service manager present on the day of the inspection said that this was an area that he was aware needed development and hoped that the appointment of a new manager would ensure that pre admission assessments were always undertaken, and that a record was held on file. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. Some improvements have been made to the individual care plans, but there is still insufficient recording of individual personal and social needs to demonstrate that needs are being met. There is insufficient evidence to show that health care needs are always met and appropriately followed up. Medication records did not reflect accurately what had been administered to the residents in all instances. Poor practice was still evidenced which may affect the health and well being of the residents who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of three permanent residents in the home were read in detail and their experience of life in the home were followed during the inspection. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 12 New care plans have been introduced since September 2006, and folders now contain a mixture of the new and old systems and it is difficult to identify up to date information, as some is undated. Records kept have improved since the last inspection but care planning is still inadequate and fails to clearly identify the care needs of each individual and the actions staff need to take to meet those needs. Residents spoken with were unaware of their care plans. There is some evidence that risk assessments have been undertaken, but this is not consistent, and where they are in place assessments are not sufficiently detailed, and have not been reviewed. One care plan identifies that a resident is at risk of falling, but there are no directions for staff to minimise the risk or how to offer assistance. Some care plans contained evidence that ‘life history’ work had been undertaken to allow the care staff to have a good idea of the background of each resident in order to offer them care in a way that is personal to them. Daily recording in care plans is undertaken by the care staff. Generally recording is poor and gives very little information, with regular entries such as ‘ no problems’ and ‘ate well today’. The daily records of one resident contained entries for a completely different resident and some records seen were found to be disjointed with subsequent dated entries written on different pieces of paper. Some entries are not written sensitively or with due regard to the dignity of the residents. There is evidence in care plans that the weight of some residents is being recorded, but again this is not consistent. One resident was noted to have gained ½ stone in 6 months but no weight had been recorded in October, and the entry for September was illegible. Catering staff had been informed of the weight gain of this resident, but were unsure of her plan of care. Another resident who is receiving all his nutrition through a ‘PEG’ tube had not been weighed for two months. The health care needs of some residents has not been efficiently addressed or followed up. One resident said she had requested to see the chiropodist and had been waiting for some months. Her toenails were found to be very long and she stated that she had resorted to ‘pulling them off myself’. A member of staff spoken with said she had no knowledge of when the chiropodist was due to visit as she said that she only works in the evening, and was unaware that the resident had long toenails Another resident was reported to have sore and red areas under her breasts and groin, which needed reporting to the doctor for treatment The next entry is six days later and there is no mention of if the GP was called or what treatment has been prescribed. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 13 There was some evidence that residents had been seen by appropriate health care professionals, with a referral noted to the speech and language therapist, and one resident seen by the consultant psycho geriatrician. During the inspection staff were seen to treat residents kindly and with due regard to their need for privacy. One incident was noted during the inspection visit of the pharmacist inspector where a carer was overheard to tell a resident to “shut up.” This is not appropriate and may be classed as a form of verbal abuse. Doors were knocked on before entry and chosen terms of address were used. On 14th November the pharmacist inspector visited the home to inspect the medicine management within the home and to assess whether the Statutory Requirement Notice issued in September 2006 detailing poor practice had been met. Audits were undertaken for a selection of medicines to see whether they had been administered as prescribed by the doctor and whether and Medicine Administration Record (MAR) charts reflected practice. One member of staff on duty was interviewed to assess her knowledge of the medicines she handles. A series of policies have been written regarding the handling of medicines, but only one member of staff had signed to say they had read and understood them. One detailed a system for receiving medicines dispensed by the pharmacist that the home no longer uses so the policy is now obsolete. The date of assessment for one staff member indicates that the Medicine Administration Record (MAR) charts accurately reflected practice. This was not the case as some discrepancies were seen. The competency assessment was incomplete, as were the competency checks. This breached one part of the Statutory Requirement Notice. Residents had been admitted to the home for respite care and no checks had been made with the resident’s doctor to confirm that the medicines they bought in were their current prescribed medicines. Some MAR charts were hand written by staff. Errors were noted. One MAR chart recorded the incorrect medication so the records did not record actually what had been administered. It could not be checked that a dispensing error had occurred, as this had not been checked with the doctor. A letter written by another home was seen and this recorded two different medicines out of the four that were seen. Staff had failed to check this discrepancy with the prescribing doctor. One resident had bought in a “medi-dose” filled with medicines. It did not record who the medicines were for, or what medicines were inside, nor was it dated. A further bottle of medicine was unlabelled, as the box with the label attached had been thrown away. Staff should always administer medicines Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 14 from a pharmacist-dispensed label in line with the Royal Pharmaceutical Society of Great Britain’s guidelines referred to in Standard 9.4. National minimum standards for older people. Staff are receiving some photocopied prescriptions after the pharmacist has dispensed them. The staff cannot check these for accuracy before they are dispensed in line with current guidelines. Photocopied prescriptions should be used to check the dispensed medicines and MAR charts received into the home. Two dispensing errors were seen and staff had not contacted the pharmacist or the Doctor in both instances. The resident did not receive the medication as prescribed by the doctor. The quantities of medicines received had not been routinely recorded for all medicines received. Audits were difficult to undertake to demonstrate exactly what had been administered. Dispensing quantities were used to calculate what had been administered where possible. One MAR chart was seen that had not been dated so information recorded would be meaningless in the future. One hand written MAR chart recorded the dose of a medicine as two tablets daily, but the administration recorded a dose being administered twice a day. This was not what the doctor intended. Medicines had been recorded as administered when they had not been. One medicine recorded that 150ml had been received but 180ml had been administered and there was none available in the trolley for any further doses to be offered. Staff had failed to notify the doctor for him to make a decision as to whether a further supply of medicines was required or to stop the medicine altogether. In another incident 9 doses of a diuretic had been recorded as administered when they had not been. Some medicines had been recorded as received but mistaken for a similar box of a different medicines. This is worrying as the incorrect medicines may be mistakenly administered. One antibiotic had been prescribed for a 7-day course. Because the resident often leaves the home the course took 11 days to complete and a further course of a different antibiotic was subsequently prescribed. No attempt was made to offer the antibiotic when the resident returned to the home. The night staff have no access to the medicine trolley so all medicines are administered by the day staff or not at all. Any resident that may require medication, for example, for pain control does not have access to any pain relieving medication. One medicine had run out and staff had failed to recognise that this had not been included on the repeat list of medicines prescribed. This resulted in the Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 15 resident not receiving one medicine for his clinical condition. The MAR chart indicated that 300ml had been dispensed but none had been recorded as received. 18 doses had been recorded as administered but none was available in the trolley for administration. This is of serious concern that staff are failing to order and check the prescribed medication received into the home or identifying when a supply is due to run out so a replacement supply can be ordered in time so there is not break in treatment. One care assistant was interviewed during the inspection and she had a good knowledge of the medicines she administered and this is commended. The home did not have current drug information sources for staff to improve their knowledge further. The manager does not undertake regular audits to demonstrate individual staff competence in the safe handling of medicines. The home has breached the Statutory Requirement Notice issued following the last pharmacist inspection and further enforcement action may be taken. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 16 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. The home does not currently provide all residents with a lifestyle they would choose, an opportunity to undertake leisure activities or to exercise choice and control. Families and friends are made welcome to the home and food provision is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not currently employ an activities organiser and entertainment from outside groups or entertainers is limited. There is an activities programme of events displayed on a white board in the entrance hall, which the deputy manager agreed required updating. The board states that an activity such as bingo or a sing-along takes place on a daily basis organised by the care staff. The board does not state what time, or where the activities are taking place, and is partly written in light yellow coloured pen, which is not clearly legible. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 17 The deputy manager said that in the past the home has employed outside entertainers, such as for music and movement, but this had not happened in a while. The last residents’ meeting took place ‘a long time ago’ where residents were asked what they might like to do, but the general opinion from staff spoken with was that the majority of residents were not interested in having a meeting, or activities in the home. On the day of the inspection a game of bingo took place in one of the lounges in the afternoon and six residents took part in this. A number of other residents sat watching television or sleeping in an alternative room, and some residents chose to spend the day in their own room. One resident likes to busy herself in the dining room, laying the tables and clearing up. She also spends time talking to the cooks in the kitchen which is connected via a ‘hatch’ who were seen to include her in their conversation. There is a new visiting hairdresser who visits the home on a Tuesday. Residents spoken with were very communicative and said that during the day they ‘didn’t do much’ and they were unaware that bingo was available that afternoon. One resident said that she would have liked to have gone out more during the hot weather of the summer, and had not been anywhere since last March. Another said that she would like to go into Coventry or Bedworth and visit the markets. During the inspection visitors were noticed to come and go from the home regularly and were made welcome by staff. Meal provision in the home on the day of the inspection was good. The dining room is bright and the decoration is appropriate. Tables are laid with tablecloths, napkins and placemats with flowers in the table centres. Condiments are available and cutlery and crockery are of a good standard. Lunch on the day of the inspection was vegetable soup as a starter, followed by gammon, mashed potatoes, and vegetables of swede, green beans and sweet corn, or cheese or ham salad. 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. Desert was apple crumble and custard, rice pudding or yoghurt or ice cream. A choice of drinks was available and staff ensured that these were regularly refreshed. The inspector ate lunch with some of the residents in the dining room. The meal was served pre plated from an order taken that morning. The food was served hot and was well presented. Residents spoken with said that they felt the choice was ‘alright’ and ‘its enough and fills you up’. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 18 Residents were unaware of what was for lunch, and there was no menu displayed. One resident said that he had ‘no idea’ what was for lunch, but said it was ‘like a surprise every day’, which he quite liked. Staff attended residents in the dining room and assisted appropriately where it was required. The cook works to a four-week menu, which looks nutritious and well balanced, a cooked breakfast is available daily and generally there is a hot tea. Food is purchased from one supplier and with the exception of salads. All vegetables are frozen. The kitchen was found to be clean and tidy although cleaning schedules were not available for inspection as the cook was reviewing these in response to a recent visit from the food standards agency. The regional manager said that all requirements made as a result of a recent environmental health visit had been actioned. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 19 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 poor. The lack of clear procedures combined with a lack of staff awareness of the protection of vulnerable adults leaves residents at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy for the home was not displayed in a public area. The deputy manager was unable to find the policy and procedure in the home’s policies. A copy of a complaints form was examined. This form is for recording any complaints or concerns a resident may have. It does not detail the contact names, addresses and telephone numbers should a visitor or relative wish to take a copy of this away to put a complaint in writing. It also does not include timescales for investigation of the complaint by the home. A complaints log was seen, however no complaints were recorded as the deputy manager said that the home had not received any complaints since the last inspection. Residents and relatives spoken with said that if they had any concerns about any aspect of the service they would discuss these with a member of staff or the regional manager. The home has an adult protection policy to give staff direction in how to respond to suspicion, allegations or incidences of abuse. This is a corporate policy, is not accurate and has not been adapted specifically for the home. For example, the policy states that any allegation of abuse should be referred to a Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 20 manager for investigation under the company’s Public Interest Disclosure Policy and Procedure (whistle blowing). It also states that any allegation of abuse by a member of staff would be investigated under the home’s staff disciplinary procedure. This is not correct, as any investigation should not commence until it has been agreed with the Adult Protection Team in Social Services. The home received one allegation of abuse, which was referred to social services for investigation and in accordance with the local arrangements for the protection of vulnerable adults. No further action was taken following an investigation into the allegation. Not all staff have received training in Protection of Vulnerable Adults (POVA), and staff interviewed confirmed that they had not attended recent training. A recently employed member of staff was not aware of the policy for ‘whistle blowing’. A senior member of staff interview was unaware on how to appropriately make a referral for investigation under the homes and local multi agency policy. A ‘News and Information’ publication was recently circulated to providers by the CSCI, which clearly details the steps a home should take when reporting an allegation of abuse. This staff member said she had not seen this circular. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 21 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, 20, 21, 24 and 26 Quality in this outcome area is adequate. The standard of décor and furnishings continues to improve with evidence of ongoing planned refurbishment and maintenance. Good systems are in place for laundering residents clothing. The management of infection control is in need of improvement to ensure poor practice does not impact on residents’ health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Communal areas of the home were being decorated during the inspection visit. The home had provided further communal accommodation for residents by converting the manager’s office into a small lounge. The dining room has been decorated including having new wooden floor covering fitted. The main lounge was being decorated during the inspection and half had been ‘curtained’ off whilst it was being painted. Residents spoken with were unsure if they had Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 22 been consulted on the changes to décor, for example, colour choice, but all said they were happy with the improvements. Eight bedrooms were seen during the course of the inspection. A number of shorcomings were seen in some bedrooms and these were discussed with the deputy manager who was present during the tour of the home. Linen and fabrics in some bedrooms were dirty and threadbare. The bed in one room had been made up with a sheet which had holes in. A mattress in one bedroom was worn and threadbare and would be uncomfortable for the resident to sleep on. Four wheelchairs were being stored in this room, which is inappropriate. The carpet in another bedroom was dirty and had burn marks. Urine smells were noted in three bedrooms. Residents have a call alarm system in their bedroom. Hot water temperatures tested in bedrooms were found to be within safe guidelines so there are no scalding risks to residents. Doors to residents’ bedrooms are not fitted with suitable locks and the area manager said that this would be rectified during refurbishment of the home. There were adequate numbers of toilets and bathrooms throughout the home. Shortcomings highlighted in the last inspection report have not been addressed. Bare light bulbs were noted in a toilet on the ground floor and in an upstairs bathroom. Toilet roll holders were missing from two toilets. The surface of the upstairs assisted bath was scratched. The bath chair was dirty and fittings were rusty. An upstairs toilet was out of order. These shortcomings do not promote infection control and good hygiene. The home had a variety of aids and adaptations available including shaft lift, emergency call system, mobile hoist and hand and grab rails. The heating, lighting and ventilation in the home appeared to meet the needs of the residents. Windows had restrictors fitted where necessary and the water temperatures checked were appropriate. The home was generally clean and odour free and there were systems in place for the disposal of clinical waste. The laundry room was well ordered and tidy and suitable facilities are available at the home for transporting soiled laundry to the laundry room. Clean and dirty laundry was separate. The wash hand basin was accessible and there was protective clothing available. Laundry is undertaken by a designated laundry assistant who also irons and folds the clean clothing. An incident of poor practice in the control of infection was observed during the inspection. A member of staff changed the bed linen on one of the beds. She was seen to transport the linen to the laundry in her arms and return with the clean bed linen. She said she had not changed her apron or gloves in between handling the soiled linen and clean linen. This puts residents at risk of infection. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 23 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 poor. Staffing levels were being maintained at adequate levels to meet the needs of the residents. Not all staff have completed the necessary training to ensure residents are in safe hands at all times and the safety of residents is not fully supported by the homes recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection there were 27 residents living in the home. Staffing levels were appropriate for the needs of the residents with four staff on duty during the working day, one of whom would be the designated senior and three waking night staff. The manager has left the home since the last inspection and the deputy manager was covering this role. The deputy manager’s hours were supernumerary to the care rota. A manager has been appointed since the inspection and has taken up post at the home. The home also employed catering, laundry and domestic staff. There was no evidence that that the new staff were receiving any induction training. The registered provider needs to ensure staff receive training in line with the specifications laid down by Skills for Care to ensure they had the necessary skills and knowledge to care for the residents. Information supplied by the deputy manager during the inspection identified that 7 of the 15 care Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 24 staff working in the home have a National Vocational Qualification (NVQ) in Care at Level 2 or above. The training in the home was difficult to track as not all staff had individual training records and some were out of date. The previous manager had produced a training matrix, but this did not have dates when the training had been undertaken, therefore we cannot be sure that all staff have the necessary skills to meet the assessed and recorded needs of residents at all times. Recruitment procedures for staff were reviewed. The files of five care staff including three care staff employed since August were examined to confirm recruitment procedures carried out. Staff files evidenced that rigorous staff recruitment checks necessary to ensure the protection of residents had not been carried out before staff were confirmed in post. For example, not all staff members had a reference from their most recent employer and two staff were employed before the outcome of their Criminal Records Bureau (CRB) disclosures were known. A statutory notice was served on the registered provider requiring the home to provide evidence that the missing documentation has been obtained. A subsequent visit to check on compliance with the statutory notice evidenced that it had not fully been complied with within the given timescale. Failure to comply may make the registered provider liable to prosecution. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 25 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 and 38 Quality in this outcome group is poor. Some practices, plus a lack of direction and guidance from management, evidence that the welfare and wellbeing of residents are not consistently protected and safeguarded and could result in risk from harm. This judgement has been made using available evidence including a visit to the home. EVIDENCE: The manager who was in post at the time of the last inspection had left and the deputy manager had been promoted to acting manager until a new manager takes up the post. The registered provider for the home needs to ensure an application for the registration of the new manager is forwarded to the commission. Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 26 At the time of the last inspection the area manager had demonstrated a commitment to addressing the shortfalls that were highlighted. At this inspection shortfalls were noted and little or no progress had been made in several areas including, risk assessments for residents, tracking of the health care needs of the residents, medicine management and robust staff recruitment practices. All these issues were again discussed with the area manager. There had been no improvements in relation to quality monitoring in the home since the last inspection. There was no evidence available to suggest that effective quality assurance and quality monitoring systems, based on seeking the views of residents, have been put in place to measure success in meeting the aims, objectives and statement of purpose of the home. The deputy manager advised she was unaware of any quality system in place to reflect and audit a set of quality standards. A visiting professional said that the home were always helpful and staff always available to discuss aspects of any clients’ care. A visitor whose relative had recently moved to the home also confirmed that staff had been pro active in helping their relative settle in. Residents’ personal money is held for safekeeping in the home if the resident or their relative requests this. Money is held in the safe in individually named plastic wallets. Individual receipts are available for all transactions and accurate records are kept of income and expenditure. Financial records of three residents were audited and found to balance with written records. Through discussion with the deputy manager, examination of records available, observation of care practices and talking with staff, it was identified that the staff team do not receive regular training, or proper induction in safe working practices. This includes, moving and handling, fire safety, first aid, food hygiene and infection control. One care member was seen to use a hoist to move a resident in the lounge. During conversation, this carer said they had not received any specific training on moving and handling since joining the home. Health and safety at the home were generally well maintained. There was evidence on site of the regular servicing of the majority of equipment. Compton Manor DS0000067096.V319348.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 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 3 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 Compton Manor DS0000067096.V319348.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 provider/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 OP3 Regulation 14(1) Requirement The registered provider must ensure that a full pre-admission assessment is undertaken on all prospective residents to ensure that their needs can be met. After consultation with the resident, or a representative, the manager must prepare a written care plan as to how the resident’s needs in respect of his health and welfare are to be met. Previous timescale of 30/09/06 not met. The registered provider must 31/12/06 demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. Previous timescale of 30/09/06 not met. The registered provider must 31/12/06 ensure that the care plans reflect all the care needs of the residents and give clear and concise guidance to the staff. DS0000067096.V319348.R01.S.doc Version 5.2 Page 29 Timescale for action 31/12/06 2 OP4 12,18 3. OP7 15 Compton Manor (Previous timescales of 31/01/06, 30/06/06 and 30/09/06 not met.) 4 OP7 15 The registered provider must ensure that there is clear evidence that the care planned is evaluated monthly and changes are made to prescribed care as required. Previous timescale of 30/09/06 not met. The registered provider must ensure that the resident and/or their family are involved in the care planning process where possible. Previous timescale not met. 31/12/06 5. OP7 15 31/12/06 6 OP8 13 7 OP8 12,13 Sch 3 The registered provider must 31/12/06 make arrangements for residents to receive where necessary, treatment, advice and other services from any health care professional. Previous timescale of 30/09/06 not met. The registered provider must 31/12/06 ensure that risk assessments are completed for all residents. Where a risk is determined a care plan must be devised describing the actions to be taken to minimise the risk. Previous timescale of 30/09/06 not met. The registered provider must ensure that all prescriptions are seen prior to dispensing, are checked and a system installed to check the dispensed medicines and MAR charts received into the home. This requirement from the 12/12/06 8 OP9 13(2) Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 30 last two inspections has not been met. Date for action by 10/05/06. 9 OP9 13(2) The registered provider must ensure that the right medicine is administered from a pharmacist labelled container to the right resident at the right dose, at the right time as prescribed by the doctor. This requirement from the last two inspections has not been met. Date for action by 11/04/06. 10 OP9 13(2) The registered provider must ensure that MAR charts record the name of the resident, start date, drug name for all prescribed medicines, correct dose and the quantities of all medicines received and balances carried over to enable audits to take place to demonstrate staff competence in medicine management. This requirement from the last two inspections has not been met. Date for action by 11/04/06. 11 OP9 13(2) The registered provider must ensure that the MAR chart is referred to before any administration and signed directly after each transaction or the reasons for nonadministration recorded. This requirement from the last two inspections has not been met. Date for action by 11/04/06. 12/12/06 12/12/06 12/12/06 Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 31 12 OP9 13(2) The registered provider must ensure that staff drug audits are undertaken before and after a medicines round to confirm staff competence in medicine management and appropriate action must be taken if these fail. This requirement from the last two inspections has not been met. Date for action by 24/04/06. 12/12/06 13 OP9 13(2) The registered provider must ensure that all dose changes are supported by written evidence from the doctor. This requirement from the last two inspections has not been met. Date for action by 11/04/06. 12/12/06 14 OP9 13(2) Enough medication must be ordered to last the 28 day cycle and any excess must be removed from the trolley to avoid the risk of duplication of administration. This requirement from the last two inspections has not been met. Date for action by 24/04/06. 12/12/06 15 OP9 13(2) The registered provider must ensure that all policies and procedures for medication are reviewed and staff trained to adhere to them. This requirement from the last two inspections has not been met. Date for action 27/09/06. 12/12/06 16 OP10 12(4) The registered provider must DS0000067096.V319348.R01.S.doc 12/12/06 Page 32 Compton Manor Version 5.2 ensure that the dignity of residents is respected at all times. 17 OP12 16 The registered provider must ensure that programme of activities in the home is developed to give all residents opportunities for stimulation which suit their needs, preferences and capacities. Previous timescale of 30/09/06 not met. The registered provider must ensure that the Complaints Policy and Procedure contains accurate information. Previous timescale of 30/09/06 not met. The registered provider must review the adult abuse procedure particularly the arrangements for reporting any allegations. Staff must be made aware of changes to this. All staff must receive training on adult abuse. Previous timescale of 30/09/06 not met. 20 OP21 12 The registered provider must ensure the surface of the identified bath is examined by a competent person and resealed or the bath replaced as necessary. Previous timescale of 30/09/06 not met. The registered provider must ensure residents’ private accommodation is fitted with appropriate locks and residents are provided with a key to their room unless their risk DS0000067096.V319348.R01.S.doc 31/01/07 18 OP16 22 31/12/06 19 OP18 12,13 31/12/06 31/01/07 21 OP24 12,13 31/01/07 Compton Manor Version 5.2 Page 33 assessment suggests otherwise. Previous timescale of 30/09/06 not met. 22 OP24 16 The registered provider must ensure that residents are provided with adequate furniture and bedding. The registered provider must ensure that robust procedures for infection control are used throughout the home. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers are as appropriate for the health and welfare of the residents. The registered provider must obtain full and satisfactory information on all employees. This must include professional references from previous employers in care, exploration of gaps in employment and evidence of qualifications. Part met Previous timescale of 30/09/06 not met. The registered provider must ensure that all new staff have induction training in line with the specifications laid down by Skills for Care and completed within their timescales. A record of this training must be maintained on site. 31/12/06 23 OP26 12 31/12/06 24 OP27 18(1) 31/01/07 25 OP29 19 Sch 2 31/12/06 26 OP30 10 31/12/06 27 OP31 8 The registered provider must 31/01/07 ensure that an application for the registration of the manager is forwarded to the CSCI. The registered provider and DS0000067096.V319348.R01.S.doc 28 OP33 24 31/12/06 Version 5.2 Page 34 Compton Manor manager must ensure that suitable quality assurance and monitoring systems are in place, actions planned are completed in a timely manner and reports available for inspection. Previous timescale of 30/09/06 not met. 29 OP38 13, 18 The registered provider must 30/12/06 ensure safe working practices through the induction process and refresher training for all staff in moving and handling, fire safety, first aid, food hygiene and infection control. Previous timescale of 30/09/06 not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP15 Good Practice Recommendations Staff should weigh residents monthly. Action should be taken as necessary with noticeable loss/gain of weight. The cook should keep a book to record all comments made about food provision, to assist with quality assurance and involvement of residents in menu planning. A menu should be displayed in the dining room to inform and remind residents what is available. 3. OP15 Compton Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Manor DS0000067096.V319348.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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