Care Home: Compass Grove

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What the care home does well The home continues to ensure that the wishes and choices of both people living in the home are supported. Both people stated they are happy living in the home and appeared to be confident and relaxed when interacting with staff and the inspector. The communal areas of the home and individual rooms were found to be clean, bright, well decorated and comfortable. What has improved since the last inspection? All previous requirements have been addressed. What the care home could do better: The missing person information contained on individual files needs to be fully completed. While both people living in the home complete their own daily record, staff must ensure these contain dates to identify specific events and timescales. CARE HOME ADULTS 18-65 Compass Grove 92 Abbs Cross Lane Hornchurch Essex RM12 4XW Lead Inspector Brenda Pears Unannounced Inspection 5th March 2008 11:00 Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 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 Compass Grove DS0000027840.V361121.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 Adults 18-65. 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. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Compass Grove Address 92 Abbs Cross Lane Hornchurch Essex RM12 4XW 01708 475915 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) chris.davis127@ntlworld.com Compass Residential Homes Limited Bernadette Ganley Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Compass Grove is registered to provide accommodation and support to two people who have a learning disability. This small terraced cottage has a delightful contemporary interior, with good attention to comfort and homemaking. Next door is Compass Cottage, a three-place care home operated by the same owners, but they are registered as separate services and have different managers. There is a third home in this group further along Abbs Cross Road called Compass Lodge. Compass Grove opened in June 2001, and for nearly all of the period since there was only one resident. In February 2006 a resident from Compass Cottage moved next door to Compass Grove, both residents having been friends over many years. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an announced inspection undertaken on the 5th March 2008 and started at 11.00am. The focus of this inspection was on the previous requirements, on the core national minimum standards and on the quality of life for those living in the home. The methods used to complete this inspection consisted of reviewing records, discussions were undertaken with the manager, with both people living in the home and also with members of staff. A tour of the building was carried out plus observations and previous findings all inform the outcomes in this report. What the service does well: What has improved since the last inspection? What they could do better: The missing person information contained on individual files needs to be fully completed. While both people living in the home complete their own daily record, staff must ensure these contain dates to identify specific events and timescales. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. These standards were not directly inspected at this time, refer to previous report for further details. EVIDENCE: Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Person centred plans were orderly and contained appropriate information to ensure the health and well being of those living in the home is maintained. EVIDENCE: Care plans are developed and signed by the individual concerned and a family member or advocate and are regularly reviewed. The missing person information contained on individual files has recently been transferred and this requires completion as forms were blank at this time. This will ensure appropriate information is quickly available in such a situation. Both person centred plans (PCPs) were seen at this time and these were up to date and contained full information. There is a healthcare section that contains information of all healthcare needs, appointments and visits. Pictures Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 10 also support statements and show outings and celebrations that have been enjoyed. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All activities are undertaken following a discussion with each person, ensuring individual choice and autonomy at all times. EVIDENCE: The outcomes for the two people living in the home continues to be good. Both residents greeted the inspector, chatted for some time in a relaxed and confident manner. Discussions around previous outings, work experience and holidays was undertaken and the plans for this years holiday were also discussed. Both people were preparing to attend the ‘Good health club’ and both stated they enjoyed attending. When asked about the staff team, comments such as ‘they are really good’ and ‘staff always help when we need it’ were expressed. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 12 Both people took complete ownership of their person centred plan (pcp) and were happy to show this and explain the sections and the information that these contained. Any daily activities are written by the person themselves and it was recommended that staff make sure these are dated. The manager has encouraged both people to do this, but where the dates are omitted, staff must ensure some time lines are evident. Both people living in the home stated they make choices about what they do and what food they eat. Shopping trips are regularly enjoyed and healthy choices are encouraged. Both people stated they are happy living in the home and a great deal of laughter was enjoyed at this time when stories were being shared between the residents. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All needs and preferences are clearly recorded on person centred plans, ensuring choices made by each individual are supported. EVIDENCE: Days are planned following full consultation with each individual and appropriate staffing levels are set. Records sampled and both observations and discussions undertaken at this time confirm that privacy and dignity is considered at all times. Healthcare appointments are clearly set out in person centred plans. Information included the appointment dates, treatment and outcomes. This is recorded in the appropriate section of each file. Medication was stored appropriately and the medical administration record (MAR) sheets were clearly competed and up to date. There is a procedure for the administration of medication and what action to take if the incorrect dosage is administered. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 14 Person centred plans also contain full details of current medication, what this is for and what side effects may occur. The manager explained that she carries out spot checks and observes practices regarding the administration of medication. Records clearly show that healthcare professionals provide appropriate support and appointments are recorded on person centred plans, as are all outcomes. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are protected by the complaints policy and procedures and by trained staff who are aware of abuse policies EVIDENCE: Complaints are appropriately dealt with and all agencies informed as necessary. The home continues to keep CSCI fully informed at all times. The complaints book was seen and contained information about recent matters that have been dealt with and outcomes were recorded. Both people living in the home said that they speak to staff about any problems or difficulties. This was also clearly shown by observation of how staff and residents interacted at this time. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was found to be clean in all areas and individual rooms comfortable and personalised, providing a homely environment that promotes well being. EVIDENCE: The home is clean, comfortable and hygienic with a very homely and relaxed atmosphere. Both people have a key to their rooms and this is observed as their own space. Both rooms were clean, personalised and comfortable. Each individual showed the inspector around their rooms and pictures of special events and outings were explained. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 17 Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff do meet individual needs, consider dignity and are trained to meet the needs of those living in the home. EVIDENCE: A sampling of staff files was undertaken and both files seen at this time contained appropriate information. This included two references, CRB and POVA first checks, ensuring the safety of people receiving support. Files also contained information of the induction process and certificates for staff training that has been completed. One fairly new member of staff has completed training in the safe handling of medication. The manager explained that work permits are also checked and appropriate training accessed for all staff. All core training is refreshed regularly and certificates are kept on staff files for reference. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 19 Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current manager is a suitable and competent person to be running the home. The manager and staff group do consider the health and welfare of those living in the home. EVIDENCE: The home was found to be clean and fresh in all areas at this time. The health and well being of those living in the home is considered and staff showed a good knowledge of individual needs. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 21 Staff are trained in safe handling of medication prior to administration and all core training is updated and refreshed where necessary. The home continues to keep CSCI informed of any events that occur in the home, following appropriate procedures. The well being and safety of service users is ensured through recruitment and training. Health and well being is ensured through support from appropriate professionals and up to date training being undertaken when necessary. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA6 YA6 Good Practice Recommendations That dates are contained on all daily records. Missing person information to be fully completed for both people living in the home. Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Contact Team Caledonia House 223 Pentonville Road London N1 9NG 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 Compass Grove DS0000027840.V361121.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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