Care Home: Compass Lodge

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What the care home does well People living at Compass Lodge are supported to be as independent as possible and to make choices about what they want. There has been a stable staff team and people are supported by staff that they know and who know them. People that want to are supported to go out in the local community. For example they are part of a healthy living club and one person belongs to the YHA (Youth Hostel Association) and visits different places and stays at hostels. He said that he liked doing this. They also go on holiday and one person said that he was looking forward to going to Hayling Island the week after the inspection and also to France later in the year. Staff said "the residents are happy and get a good service". What has improved since the last inspection? The requirements from the last inspection have all been met. The dietician has reviewed the menus and two people go to a healthy living club so they are supported and encouraged to eat and to be healthy. Fire safety & environmental safety work has been completed so that the building is safer for everyone using it. People`s files now contain details of their medical appointments and they have health action plans. A new washing machine has been purchased so that laundry can be appropriately washed. What the care home could do better: Some of the medication records need to be better so that people can be sure of getting their medication as safely as possible. The owners need to vary the dates of the monitoring visits so that they are completely unannounced and not expected. All staff need to be aware of and carry out health safety checks so that they have a better understanding of their responsibilities under health & safety and so that checks are carried out regularly. Staffing levels and rotas need to be reviewed so that enough staff are on duty to provide a good service to people living there and so that staff taking responsibility for the shift/service and the people living there are clearly identifiable. The steps at the front of the building are difficult for one person to manage and these need to be changed or other ways of entering the building need to be used to lessen the risk of falls and to enable people to enter the home as safely and easily as possible. CARE HOME ADULTS 18-65 Compass Lodge 121 Abbs Cross Lane Hornchurch Essex RM12 4XR Lead Inspector Jackie Date Key Unannounced Inspection 3rd September 2008 10:00 Compass Lodge DS0000027841.V371399.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 Lodge DS0000027841.V371399.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 Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Compass Lodge Address 121 Abbs Cross Lane Hornchurch Essex RM12 4XR 01708 502179 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) c.davis37@ntlworld.com Compass Residential Homes Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 5th September 2006 Date of last inspection Brief Description of the Service: Compass Lodge is a four bedded home for adults with learning disabilities. The owners have two other homes in the area. They are a few minutes away in the same road. People tend to spend time in all of the three homes and staff cover in all three homes when needed. The area manager is in the process of applying to be the registered manager of Compass Lodge. At the time of the visit two men and a woman were living in the home. It is in a residential area of Hornchurch close to local shops and amenities and to local transport networks. On the ground floor there is a single bedroom, a toilet and shower room, a small kitchen and a dining and living area. On the first floor there are three single bedrooms and a bathroom. There is a small rear garden with a patio. The former garage to the side has been split to create a laundry and storeroom, with the other half converted as the office. The people living at the home are supported in community-based activities by the staff team. The scale of charges per week for each person range from £800 to £1600 per week. This information was taken from the Statement of Purpose. Information about the service provided is contained in the service users guide. Compass Lodge DS0000027841.V371399.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 inspection was unannounced and started at 10 am. It took place over six and a half hours. This was a key inspection and all of the key inspection standards were tested. Staff were asked about the care that people using the service receive, and were also observed carrying out their duties. People using the service were asked to give their views on the service and their experience of living in the home. All of the shared areas and bedrooms were seen. Staff, care and other records were checked. There were not any visitors at the home on the day of the visit and it was therefore not possible to discuss the service with relatives. Services are now required to complete an AQAA (Annual Quality Assurance Assessment). The last completed form was received in October 2007 and the next AQAA (Annual Quality Assurance Assessment) will be sent to the service in the near future for completion. The inspector would like to thank the people living at Compass Lodge and staff for their input during the inspection. What the service does well: What has improved since the last inspection? Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 6 The requirements from the last inspection have all been met. The dietician has reviewed the menus and two people go to a healthy living club so they are supported and encouraged to eat and to be healthy. Fire safety & environmental safety work has been completed so that the building is safer for everyone using it. People’s files now contain details of their medical appointments and they have health action plans. A new washing machine has been purchased so that laundry can be appropriately washed. 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. Compass Lodge DS0000027841.V371399.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 Lodge DS0000027841.V371399.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): 2, 3, 4 & 5. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Appropriate information would be gathered on people before they move into the home and this would give staff a picture of the individual’s needs and how to meet these. People thinking of moving into Compass Lodge and their relatives can spend time in the home to find out what it would be like to live there and to enable them to make a choice about living in the home, within their capacity to do so. People have contracts and therefore have information about the service that they are entitled to. EVIDENCE: There have not been any new admissions to the home since the last key inspection in September 2006. The process for admission is the same as at the other homes owned by the proprietors. In that an assessment would be obtained from the placing authority and an assessment made by the manager of the home. Any other relevant assessments, for example, from an occupational therapist or a speech and language therapist, would also be Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 9 obtained. Therefore sufficient information would be gathered on that person to enable their needs to be identified and for a decision to be made about the home’s capacity to meet their assessed needs. The person would be invited to visit the home on occasions and meet the other people living there. Therefore, when possible, people are given the opportunity to visit the service and to meet staff and other people living there before they decide if they want to live there. Evidence that this process is used was found during a recent visit to another home owned by the proprietors. People have individual contracts between themselves and the provider. The contracts were available at the home and copies were seen in peoples’ files. Therefore they have details about the service that they are entitled to. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 10 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, 8 & 9. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Peoples’ care plans contain sufficient information to enable staff to meet their needs. Improving and reviewing risk assessments will enable this to be done as safely as possible. People are consulted about what happens in the home. EVIDENCE: Each person has a plan which gives details of how they need/like to be supported. Areas covered included education, vocational, leisure, spiritual, and cultural need. All three care plans were examined during the visit and information contained in them was appropriate and relevant. They also indicate what individuals like and dislike. For example one person’s care plan states that they he likes bowling and swimming. Care plans seen were up to date and had been appropriately reviewed with the person, and when appropriate their relatives and representatives. All three people have ‘communication passport’s. These give guidance on how each person communicates and also guidance on how to communicate with each person. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 11 Therefore plans contain appropriate and current information so that staff can meet peoples needs. Daily recordings are made about what each person has done and support that they have been given. Some of these recordings tend to be quite general and a bit limited. This is an area for ongoing development and the manager is aware of this. There is information about each individual, which can be used as part of the review process and to identify ongoing and changing needs. Improving the quality of this information will assist this process. Risk management strategies are in place and these identify and indicate ways in which the risks can be reduced to enable peoples’ needs to be met as safely as possible. The risk assessments for one person had not been dated and there was not any evidence to confirm that they had been reviewed or updated. Additionally these did not fully cover areas of risk. For example this person requires one to one support to move around the home but needs the support of two people to get down the steps at the front of the house. Risk assessments need to cover all of the necessary areas and need to be dated and reviewed regularly to ensure that staff have up-to-date information about risks and how to minimise them. This will help to keep everyone safe. However people are supported by a small number of regular staff that know them well. The member of staff on duty on the day of the visit worked mainly at one of the other homes but she was able to demonstrate a good knowledge of the people living at Compass Lodge and of how to meet their needs safely. One of the people living at Compass Lodge can express his views about what he wants to do and what he likes. The other two people have very limited communication but staff said that they could both indicate when they do not want something and can choose what they want when shown the options. One of these people has had the involvement of an independent advocate to support him. People are encouraged to make decisions about what happens as far as they are able. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 14, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. People are encouraged to take part in activities and to be part of the local community and have an active social life People are supported to keep in contact with their relatives. People are supported and encouraged to have a diet that is healthy and meets their needs. EVIDENCE: One of the people living at Compass Lodge does not always like to go out, it is felt that this is because he does not like a change or new places. He does go to some of the clubs and likes going to the pub. He also likes to go to the local shop to buy a coke and a mars bar. This was evident during the visit as he put his shoes on when he was ready to go to the shop and then changed back into his slippers when he got back. Another person was talking about going on Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 13 holiday but when we asked the first person if he wanted to go he clearly answered no. The other two people enjoy going out and both go to a healthy living club on Wednesdays and this includes members of the general public. They get advice on healthy eating and also do activities such as line dancing and salsa. One of the people living there had just returned from a short trip and had stayed at youth hostel in Oxford. He also goes to a day centre for one day a week and enjoys the cinema, bowling and going out for walks. He is about to start a small part time job once a week at a city farm. He said that he was looking forward to his holiday at Hemsby Beach and that he was going to France later in the year. This person has participated in some staff training and has got certificates for attending these. Feedback from staff was that it would be good if they could get one of the people to go out more but that the others go out quite a bit. Sometimes they join the people living at the other Compass homes for activities and social events. All of the people using the service have contact with their families and families visit the home and come to any parties or celebrations. One person goes out with his sister. Another person said that his father was going to visit him while he was on holiday the next week. People are encouraged and supported to be as independent as possible and to do things for themselves. One person rinses plates and dries up and puts things away. Another brings the washing in. Care plans include ways in which people are encouraged to be independent. For example “support him to run his bath”, “he can hoover and wash up”. People are also supported to make choices about when they get up. For example one person is up at about 6am and he is supported with his personal care and breakfast by night staff. Another person does not like to get up early and stays in bed until about 9am unless she is going out and needs to be up early. On the day of the visit she was just having breakfast when we arrived. All three people are able to indicate food that they like and don’t like and are offered choices to help them to do this. One person, on the advice of the speech and language therapist, needs to have a soft diet with sauces and gravy and has to have their drinks thickened to assist with a swallowing difficulty. The dietician has been consulted and has advised on menus. As previously stated two people do attend a healthy living club and get advice and guidance on healthy eating there. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 14 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. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. People using the service receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. People are given their regular prescribed medication safely but medication records need to be more robust to minimise the risk of errors and to provide a more accurate record of medication administration. EVIDENCE: People living at Compass Lodge need differing amounts of help with personal care and this is specified in the care plans. One is fairly independent and requires reminders, prompts and minimal supervision. The others need more support. When given a choice one person points to the clothes she wants to wear and also to the jewellery she wants. This person does not always like to have her hair washed but enjoys going to the hairdresser so goes there most weeks. Another person is not keen on being shaved and on the day of the inspection was not shaved but when we asked him if he wanted to have a Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 15 shave he said no. On the day of the visit the people living there were appropriately dressed. The staff provide the support that people need to maintain a good level of personal hygiene and also to maintain their independence. All of the people using the service go to the local doctor and specialist help is received from the community learning disabilities team. There was also evidence of input from a speech & language therapist and the dietician. Staff support people to all of their medical appointments. People have had checks from the optician, dentist and when appropriate chiropodist. ‘Health action plans’ are in place and records are kept of appointments and outcomes. As previously stated people have joined a healthy living club and are encouraged to keep themselves as well as possible. One person had been refusing dental treatment but with good support from staff was now accepting this and went to the dentist on the day of the visit. Therefore people are well looked after in terms of their healthcare needs. None of the people living in the home are able to self medicate and staff administer medication. The manager trains staff to administer medication using a training pack & DVD. Staff have to complete a questionnaire and are monitored and observed. They also do an in house test. They cannot administer medication until they have been deemed competent. Medication is securely stored in a locked cabinet in the hallway. In line with good practice the medication file has photographs of people that take medication and details of any allergies. Medication administration records are kept and are up-todate. People taking medication have had medication reviews. This is also good practice. Examination of the MAR (Medication Administration Record) found that these had been completed. However there were some instances when the code “O” had been used indicating that the person had not had their medication. There was not any explanation of why this was the case recorded. If a person does not have their prescribed medication for any reason then the reason must be recorded on the reverse of the MAR (Medication Administration Record). This will then clearly identify what the issue is so that it can be addressed with the person, staff or the G.P. Also one person is prescribed a laxative twice daily but does not receive this regularly because it is not required. This needs to be reviewed with the G.P and if necessary discontinued or changed to a PRN (as required) medication. One person has PRN (as required) medication but there are not any guidelines or a protocol for the administration of this medication. Guidelines/protocols must be in place for the administration of any PRN (when required) medication to assist staff as to when and how to administer this medication. This will ensure that staff are clear about the administration of this medication and it will also lessen the risk of error. It is recommended that the medication file also contain a list of staff that are able to administer medication and a sample of their initials. This is good practice and helps to easily identify who has been responsible for the administration of medication and when. In the office there Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 16 is a copy of a BNF (British National Formulary) book that gives information about medication. This was dated March 2006. It is recommended that an upto-date edition be purchased to ensure that staff have access to the latest information. All of this will help to ensure that people receive their prescribed medication as safely as possible. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 17 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. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. There is a complaints procedure that is followed in the event of any complaints being made. Staff have received safeguarding adults training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. Appropriate action was been taken when a safeguarding issue occurred. This gives people a greater protection from abuse. EVIDENCE: There is a complaints procedure, which is displayed in the home. One person living at Compass Lodge is able to say if he is not happy about anything and another has access to an independent advocate. There were three recorded complaints and these had been appropriately dealt with. The service has a safeguarding adults policy and procedure and staff have received safeguarding training. This forms part of the induction, part of NVQ training and the proprietor also provides refresher training. Staff were aware of safeguarding issues and their responsibilities to those using the service. Staff spoken to said that they did not have any concerns about the care of people living at Compass Lodge and felt that they received good care. Previous reports have said that the manager and owners have correctly followed the necessary procedures when there has been a suspicion of a safeguarding issue. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 18 The three people living at Compass Lodge receive their money in different ways. One goes to a local building society with staff and signs to collect his own cash. The service is advancing money to another person until appropriate arrangements can be made with the Court of Protection. The third receives benefits via a giro, which is cashed by the manager. The manager is going to organise for a building society account so that in future benefits can be paid directly into the persons account. Each person cash is kept in tin in the safe. Appropriate records are kept and receipts are obtained as far as possible. The cash held for all 3 people was checked during the visit and some small discrepancies were found. This was due to the fact that people had gone out to a club and money had been taken for this but details had not been left in the cash tins. It is recommended that whenever any cash is taken from the cash tins a note is kept of this. This will give a clear audit trail of monies and lessen the risk of any mistakes or confusion. Cash held is checked each handover and had been correct at the time of the last handover. Two people had quite a lot of money in their tins and as an extra safeguard it is recommended that for each person a small amount of day-to-day cash is kept in a tin in the office at the home. The remainder of their cash and any documents can stored in the safe of the managers office with limited access. This system is in place in another of the Compass Homes and is more robust Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 19 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, 25, 26, 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. People live in a clean comfortable home that is the main suitable for their needs. Alterations to the front entrance would make it easy and safer for people to use. EVIDENCE: The home is in a residential area of Hornchurch close to local shops and amenities and to local transport networks. On the ground floor there is a single bedroom, a toilet and shower room, a small kitchen and a dining and living area. On the first floor there are three single bedrooms and a bathroom. There is a small rear garden with a patio. The former garage to the side of the garden has been split to create a laundry and storeroom, with the other half converted as the office. There is a side entrance to the house but we were told that people use the front entrance, which is accessed by a small set of steps. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 20 The lounge/dining area is adequately decorated and furnished and there are a number of photographs and pictures displayed on the walls. Each person has a single bedroom and all three people agreed to show us their room. These are appropriately furnished, decorated and personalised. On the first floor there is a bathroom with a bath and toilet. There is also a shower and toilet on the ground floor. One of the people living at Compass Lodge has very poor mobility and uses a wheelchair when out in the community. This person has the ground floor bedroom and can use the shower facilities, which are adapted for this persons needs. Therefore the bathing/shower facilities are suitable for the people living there. The person with mobility problems is able to get around the ground floor of the home with the support of one staff. However two staff are required to support this person on the steps at the front of the building, as these steps are not suitable for a person with a mobility problem. On the day of the visit this person left and entered the building via these steps. The building needs to be suitable for all of the people living there and therefore arrangements need to be made to either alter the access to the front of the building or to make the second entrance easily accessible and to use this. This will be much easier for the person and will also lessen the risk of falls and injury to staff and people using the service. At the time to visit the home appeared to be clean and hygienic and the requirements of an environmental health report in November 2007 had been met. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 & 36. People using the service experience adequate quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Staff have the opportunity individually and collectively to discuss their own development or any problems and developments within the service and feel supported by the manager. Staff are receiving the necessary training to give them the skills to meet peoples’ current needs and provide an appropriate service for them. People using the service are supported and protected by the organisations recruitment practice. Whilst the flexibility of staff from other Compass homes supporting people at this home for parts of the day means that people are supported by staff that they know it is not evident that there are sufficient staff on duty to meet peoples needs in a flexible and person centred way. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 22 EVIDENCE: One staff is on duty during both day and night shifts. On some occasions there is also a mid shift staff covering from mid morning to late afternoon. The manager is based at this service and she also provides support and support is provided from the other Compass homes as people do go to some things together. However it was not possible to clarify which staff were supporting people at any one time. On the day of the visit the home had one permanent member of staff, who works mainly at another Compass home, and one person who was starting induction on duty. The manager was not on duty but did come to the home to assist with the inspection. One person had an appointment and a senior member of staff from one of the other homes came to escort her to the appointment. We were told that when four people lived in the home two staff were on duty and that if a fourth person moves in the staffing levels will be increased. Staffing levels must not be based on the numbers of people but the level of support that is required. From observations during the inspection, examination of the rota and discussions with staff it was not possible to confirm that there were always sufficient staff on duty to meet people’s needs. This takes into account the fact that at present the manager is responsible for all three of the Compass homes. The registered provider must review the staffing arrangements in relation to the assessed needs of the people living at Compass Lodge. The rota must clearly state who will be on duty in the home and this includes staff from other homes working in Compass Lodge for specified periods. If the manager is working as part of the shift this must be clearly identified. This will ensure that sufficient staff are on duty to provide a good service to people living there and that people taking responsibility for the shift/service and the people living there are clearly identifiable. The service operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. A random sample of three staff records were checked. The files contained copies of the application form, interview questions and interview assessments. There was also evidence that the necessary checks had been carried out. This includes references, identification, POVA (Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) checks. Therefore the recruitment procedure offers safeguards to people using the service. From discussions with staff and looking at records it was apparent that the appropriate training is being provided to staff. All staff have had induction training and other training has included protection of vulnerable adults, medication, communication, food hygiene, fire safety, makaton and epilepsy. Of the twelve permanent staff working in the Compass services eight have achieved NVQ level 2 or above and 3 are working towards this. Therefore the staff team are being provided with the training and skills that they need to meet the needs of the people using the service. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 23 Staff meetings are now being held monthly. Staff spoken to said that they do receive supervision and that this had been “fairly regular”. The main reason for this had been the changes in management arrangements. The new manager has started supervising staff herself with a view to senior staff doing this in the future. This gives staff collectively and individually an opportunity to discuss concerns, the care of people using the service and the development of the service. There was evidence on file that staff have had annual appraisals and that training and development needs have been identified. Staff spoken to said that they get good support and that the manager understands and is really helpful. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 24 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, 38, 39 & 42. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. People living at Compass Lodge benefit from a service that is appropriately managed and where their views and opinions are sought and acted upon as far as is possible. People live a safe home but systems need to be in place to ensure that all statutory checks are carried out within the specified time frame. EVIDENCE: Since the last inspection there has been changes in management. The new manager is also the area manager and she will be the registered manager for Compass Lodge and also Compass Cottage. She will oversee Compass Grove. She has a NVQ qualification and has obtained the RMA (Registered Managers Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 25 Award) and has also worked in the Compass homes for many years. The manager is now in the process of doing a skills for leadership in care course. She is aware of areas that need to be developed and improved and has started to work towards this. The manager has the necessary skills and experience to manage this service. Feedback from staff was that the manager was supportive, helpful and approachable. The manager has not yet made an application to be registered with the Commission. In line with procedure she has completed all of the necessary paperwork and has obtained the information and checks required. She had received her CRB (Criminal Records Bureau) check during the week of the inspection and is now able to submit the application to the Commission. The staff team carries out all of the necessary health and safety checks. For example fire call points are tested, as are hot water temperatures. These are tested most weeks but there are gaps when this has not happened. This was discussed with the manager and it is recommended that all staff take responsibility for this task, perhaps on a set day, so that there are not gaps when a designated member of staff is on leave or absent for other reasons. It will also help to raise staff awareness of Health & Safety issues and responsibilities. Appropriate servicing is carried out on the fire system and fire equipment. Fire safety requirements made by the fire service in 2006 have been carried out. Records show that there have been three fire drills held this year. As stated previously one of the people living at Compass Lodge has limited mobility and it might not be possible for one member of staff to evacuate all three people in the event of an emergency at night. It is recommended that the fire procedure be reviewed to take this into account and amended if necessary. The manager said that she will discuss this with the representative of the company that provides fire safety advice and training. Portable appliances have been checked recently and items that were not satisfactory were replaced. The electrical intake was tested as safe in 2006 and this is still valid. However the gas safety certificate expired in February 2008. This must be renewed each year. A satisfactory Gas Safety certificate must be obtained to confirm that gas appliances and systems are safe. The quality of the service provided to people using the service is monitored by the manager and by the proprietor. For example the manager has recently completed night spot checks and surveys have been sent to relatives to get feedback from them. Monthly monitoring visits were carried out by one of the proprietors to assess how effectively the home is operating to meet its stated aims and objectives, and reports were written. These indicate the action to be taken when deficiencies are identified. However this proprietor has been unable to carry out these visits for a while and the last recorded visit and report on file was in November 2007. The manager did say that another proprietor visits regularly and that there is very regular contact with the proprietors. The proprietor said that reports had been written as a result of Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 26 the recent visits but had not been left at the home as on previous occasions reports had ‘disappeared’. The proprietor has subsequently sent copies of these reports to us. Thus confirming that the service is being monitored. However it is recommended that a copy of these reports are made available at the home and that they are discussed with and accessible to staff. This will give feedback on the quality of the service and also help to make all staff aware of areas of good practice and of any shortfalls that need to be addressed. We noted that many of the monitoring visits took place on the 30th of the month. The regulation does require that these visits are unannounced and therefore the proprietor needs to vary the date, day and time of the visits. Compass Lodge DS0000027841.V371399.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 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 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 2 X Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 28 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. 1. Standard YA9 Regulation 13 Requirement Risk assessments must cover all of the risks to each person and must be dated and reviewed regularly so that peoples’ needs can be met as safely as possible. Protocols/guidelines must be in place for any PRN (as required) medication. Staff will then be clear as to when, how and why to administer this medication. If a person does not have their prescribed medication for any reason then the reason must be recorded on the reverse of the MAR (Medication Administration Record). This will then clearly identify what the issue is so that it can be addressed with the person, staff or the G.P. The building needs to be suitable for all of the people living there and therefore arrangements must be made to either alter the access to the front of the building or to make the second entrance easily accessible and to use this. This DS0000027841.V371399.R01.S.doc Timescal e for action 30/11/08 2. YA20 13 31/10/08 3. YA20 13 31/10/08 4. YA29 23 31/03/09 Compass Lodge Version 5.2 Page 29 5. YA33 18 6. YA42 13 will be much easier for the person with a mobility problem and will also lessen the risk of falls and injury to staff and people using the service. The registered provider must 31/10/08 review the staffing arrangements in relation to the assessed needs of the people living at Compass Lodge. The rota must clearly state who will be on duty in the home and this includes staff from other homes working in Compass Lodge for specified periods. If the manager is working as part of the shift this must be clearly identified. This will ensure that sufficient staff are on duty to provide a good service to people living there and that staff taking responsibility for the shift/service and the people living there are clearly identifiable. A satisfactory Gas Safety 15/10/08 certificate must be obtained to confirm that gas appliances and systems are safe. Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 30 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 YA20 Good Practice Recommendations It is recommended that the medication file contains a list of staff that are able to administer medication and a sample of their initials. This is good practice and helps to easily identify who has been responsible for the administration of medication and when. It is recommended that an up to date copy of the BNF (British National Formulary) book be purchased to ensure that staff have access to the latest information. It is recommended that whenever any cash is taken from the cash tins a note is kept of this. This will give a clear audit trail of monies and lessen the risk of any mistakes or confusion. It is recommended that for each person a small amount of day-to-day cash is kept in a tin in the office at the home. The remainder of their cash and any documents can stored in the safe of the managers office with limited access. This system is in place in another of the Compass Homes and is more robust It is recommended that a copy of the proprietors monthly monitoring reports are made available at the home and that they are discussed with and accessible to staff. This will give feedback on the quality of the service and also help to make all staff aware of areas of good practice and of any shortfalls that need to be addressed. It is recommended that all staff take responsibility for regular health & safety checks, perhaps on a set day, so that there are not gaps when a designated member of staff is on leave or absent for other reasons. It will also help to raise staff awareness of Health & Safety issues and responsibilities. It is recommended that the fire procedure for nights be reviewed to take into account the restricted mobility of one person and amended if necessary. This will help to protect everyone in the building in the event of a fire at night 2. 3. YA20 YA23 4. YA23 5. YA39 6. YA42 7. YA42 Compass Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Office 4th Floor 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 Lodge DS0000027841.V371399.R01.S.doc Version 5.2 Page 32 - 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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