Care Home: Compton Care (Staffs) Limited

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What the care home does well People living in this home can be confident the manager will visit them before they move in. They will do this so that a full assessment of people`s needs can be completed. The people who use the service are treated as individuals and the staff ensure they make day to day life as pleasurable as they can. Access to a clear Service User Guide and complaints procedure, written in a format people understand, ensures their rights are respected. There is an ever widening range of activities on offer within the home and in the community. People are encouraged to take part in the daily routines of the home where possible. Plans of care are well written offering information on daily routines, choices, likes, dislikes and preferences. This shows the service looks at every individual independently to ensure their needs are met. Good plans of care give the staff the information and confidence needed, and demonstrates they are aware of individuals needs and are able to meet them. Behavioural plans of care are in place which means staff can support people in a consistent and considered way. Health care monitoring is well recorded and which includes weight charts, this means people are fully supported with their health requirements. Staff practices support people to live a lifestyle of their choice ensuring their best interests. What has improved since the last inspection? This is not applicable as it is their first inspection. What the care home could do better: Medication practices and systems need to be managed better. This is to ensure that people using the service receive their medication to promote their health, and that risk of harm through error is minimized. Recruitment practices must be improved upon to fully support and safeguard people who use the service. Mandatory training must be a priority for those staff who require it, this is to ensure they have the knowledge and skills to meet the needs of the people who use their service. The home needs to consider how each person would be evacuated in the event of a fire and to seek advice. This means people are kept safe. Policies and procedures need to be either considered or expanded upon, this means there is clear and accurate information for people to refer to. The agency should continue to review and update all policies and procedures in place in line with good practice guidelines and changes in legislation. The service could improve the way they record managing risk. This means everyone is protected and people are not left in a vulnerable or compromising situation. All records should be signed and dated to offer clarity of information. The home needs to ensure they record all accidents and incidents that occur in the home well. Systems and structures put in place now need to be embedded; this means the manager has clear audit trails and clarity of information. Key inspection report Care homes for adults (18-65 years) Name: Address: Compton Care (Staffs) Limited 38 Church Lane Stoke-On-Trent Staffs ST4 4QB     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Rachel Davis     Date: 1 1 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Compton Care (Staffs) Limited 38 Church Lane Stoke-On-Trent Staffs ST4 4QB 01782646716 01782616716 james141248@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Compton Care (Staffs) Limited Name of registered manager (if applicable) Mr Richard John Clarke Type of registration: Number of places registered: care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is 5 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 Learning Disability Code LD maximum number of places 5 Date of last inspection Brief description of the care home Compton Care is a two storey detached building located on a residential road in the Hanford district of Stoke on Trent. It is registered to support five people with a learning disability. The outside features of the building are similar in design and structure to that of neighbouring properties. The service is close to local bus routes for the centre of Stoke on Trent and Hanley. Each bedroom has en-suite shower facilities with a wash hand basin and toilet. One of these rooms also has a bath. The bedrooms are furnished and decorated to a high standard. A separate bathroom with toilet and Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 5 Brief description of the care home wash hand basin is located on the first floor. There is a large spacious lounge and separate dining room. There is also a conservatory and another room which can be used as a sensory or relaxation room. A staff sleep in room is located on the first floor and the office is located on the ground floor. Appropriate kitchen and catering equipment is available and a lawned garden is provided which is safe and secure. There is a separate laundry area with relevant style domestic equipment provided and a sluice facility is in place. The service was registered with the Care Quality Commission on 27th January 2010; the registered manager for this service is Richard Clarke. Fees are £1,295.00 per week, readers wishing to know more about this should contact the service directly. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection focused on the outcomes for people using the service. The key inspection was announced this means the people who use the service and the staff team know we are coming. This is the first inspection for this service since it was registered with us in January 2010. The purpose of the inspection is to assess the outcomes for people who use the service, using the National Minimum Standards and Regulations for Care Homes. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent, good, adequate or poor based on the findings. A newly registered agency cannot be an excellent service on its first inspection because they have not had the time to demonstrate sustainability. In order to prepare for this visit we looked at all the information we have received. We look at what the home has told us about things that have happened in the service, these are called notifications and are a legal requirement. Care Homes for Adults (18-65 years) Page 6 of 30 We read the annual quality assurance assessment (AQAA). This is a self assessment that focuses on how well outcomes are being met for the people using the agency. Useful information should be offered in the Annual Quality Assurance Assessment and it was completed by the registered manager prior to the key inspection taking place. We send surveys to a sample number of people with links to the service, including people using the agency, other professionals and staff members. In this instance there were not any staff or people using the service when these were sent. During the inspection process we look at the way staff are recruited and trained and if the service is being managed effectively. We also check any necessary health and safety documentation, the complaints folder and plans of care. Care Homes for Adults (18-65 years) Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: Medication practices and systems need to be managed better. This is to ensure that people using the service receive their medication to promote their health, and that risk of harm through error is minimized. Recruitment practices must be improved upon to fully support and safeguard people who use the service. Mandatory training must be a priority for those staff who require it, this is to ensure they have the knowledge and skills to meet the needs of the people who use their service. The home needs to consider how each person would be evacuated in the event of a fire and to seek advice. This means people are kept safe. Policies and procedures need to be either considered or expanded upon, this means there is clear and accurate information for people to refer to. The agency should continue to review and update all policies and procedures in place in line with good practice guidelines and changes in legislation. Care Homes for Adults (18-65 years) Page 8 of 30 The service could improve the way they record managing risk. This means everyone is protected and people are not left in a vulnerable or compromising situation. All records should be signed and dated to offer clarity of information. The home needs to ensure they record all accidents and incidents that occur in the home well. Systems and structures put in place now need to be embedded; this means the manager has clear audit trails and clarity of information. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the necessary information and have been suitably assessed prior to moving into Compton Care. Evidence: The AQAA tells us: We intend to ensure that all our service users are fully assessed and we intend to work closely with the local authority and commissioning team, we will work within a person centred approach. We could evidence on inspection this was an accurate account. The service has a Statement Of Purpose and Service User Guide, these set out the aims and objectives of the home, and include information about the service. The documents are made available in a format appropriate to the people who use the service, individual capacity and language. The home are considering an audio version also. The Service User Guide includes the fees payable; this means prospective people have information on the costs involved. We recommend this is further developed to include information on what people do or do not pay for regarding support from staff e.g. when on holiday, day trips meals out etc. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: We were able to look at the recods for a person who had recently been admitted into Compton Care. The home had gathered information on their needs and covered details on maintaining their safety, health, social and psychological care and the support that people that use services needed. Information was obtained about their life histories so staff had information about their lives before they moved into the home. All records required from the commissioning team were in place and an appropriate transition had been undertaken to ensure moving into the home was made as easy as possible They told us: I like it here, Im happy and I have a very big bedroom and can make as much noise as I like Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Plans of care offer all the required information to fully support the people who live at the home. Evidence: The AQAA demonstrates people have a support plan, the plan tells staff about the persons assessed care and social needs and how these can be met, so their health and independence can be assured. People told us they were actively involved in planning their care, enabling them to maintain daily routines that reflected their lifestyle and personality. People had signed their plans to confirm they agreed with the content. Overall support plans are well documented and there are clear day to day records to confirm how people wish to live. We spoke with staff who told us they really liked working at the home and felt well supported. They had been asked to read all information pertaining to people living in the home to ensure they had as much information as possible to help them Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: understand individuals needs, goals and aspirations. We noted that behavioural management plans are in place, this means there are clear instructions for staff to follow and ensures consistent and appropriate care management is provided to the people who use the service. The manager needs to ensure that all written records are dated and signed, this means there is clarity for review and a named person to refer to, regarding the information recorded. We are satisfied that other professional support is requested when necessary e.g. from the district nurse or doctor as records verified this. We have recommended the home provides a professional visits form so this information is easily accessed for reference within the support plan. Risk assessments are in place but in some instances should offer clearer information because they were in a number of instances generic. They need to be tailored to individuals, for example there was little information to verify what tasks could be undertaken in the kitchen safely, and if not what support is required. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Support is given to promote peoples rights and independence. People are able to enjoy a full and stimulating lifestyle; routines are flexible meaning people make choices in all areas of their life. Evidence: The AQAA tells us: We intend to integrate new service users within their community and to develop meaningful activities that provides person centred choices for individuals. We spoke with one person using the service who told us they lived a full and busy life. They told us about their part time job and how people are talking to them about other interests and how to achieve these. There was evidence people had influence over the running of the home and were involved in the day to day running. People had keys to their bedroom and the front door and were able to take appropriate risks. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: We looked at the plan of care for one people using the service; we also talked to staff about how they support people using the service. Plans show there are opportunities to maintain and develop social skills and take part in appropriate activities, for example going to work, shopping, visiting friends, eating out. Everyone participates in the homes food shopping and their personal shopping. They access community facilities for activities and health appointments. People receive varied meals and have chosen to plan their menus on a daily basis. Staff confirmed issues such as meals were discussed regularly and there was pictorial information available to assist people in making choices. People prepare meals with support, and a range of foods are available in stock to facilitate choice. There is a good selection and ample quantity of fresh fruit and people are free to help themselves. Healthy options are available and weight and diet are regularly monitored. We recommend he home seeks advice to ensure the menus are nutritionally balanced; they should also further develop ways of supporting people to make choices with additional aids. The home still requires an inspection from Environmental Health, the responsible individual told us he would contact them to arrange a visit. Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people living at the home are met. Medication is securely stored but improvements are needed within their policy and recording systems. Evidence: The AQAA tells us: We will ensure service users health care needs are met and that service users are maintaining a level of independence around their own developing life that they feel comfortable with. We looked at the health care provided to one person living at the home. We can see that they have had a range of routine health screening with, for example, the dentist and doctor to ensure any changes in health can be identified and acted on early. We recommend the home uses a professional visit record so the information is clearly visible with an audit trail to ensure appointments are undertaken when required. Weight charts are being completed for the people who use the service and staff can clearly refer to these to ensure weight is appropriately maintained. We were able to see people who use the service on the day of inspection. They were well dressed, Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: clean and presented as being calm and comfortable. We talked to staff who said they had no concerns about peoples current health. We looked at medication management and found that we could not audit the medicines the home had obtained because they do not keep an accurate tally of the medication. Audits were therefore difficult to undertake to demonstrate that they had been administered as prescribed and records reflected practice. An as and when required (PRN) protocol and policy are not in place and need to be provided. This will help to support the staff in decision making. The homes medication policy needs further information to ensure it covers all areas of practice. The home should consider ways to monitor competency around medication practices. This will assist in ensuring a safe service is continually promoted. The manager confirmed they would use homely remedies if necessary. However, there is not a policy which needs to offer a list of homely medications preparations that may be used and a brief description of what they should be used for. The home needs a policy which is specific and offers protocols. The home understands the need to comply with the administration, safekeeping and disposal of drugs. Medication systems need to be improved to ensure they follow safe practice guidelines. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are clear procedures in place, but further policies need to be developed. This will ensure that people using the service are protected and safeguarded from harm or abuse. Evidence: We can verify the home has a complaints procedure, which is made available to people in an appropriate format when they move in. There have not been any complaints since the service was registered in January 2010. We recommend a grumbles /comments book so that all comments have the opportunity to be evidenced to support the service with identifying how changes are made to improve the services for the people who live there. Safeguarding Adults is a process of identifying and reporting suspected or potential abuse to vulnerable people and provides a framework of consistency to protect those individuals who are at risk. During our inspection we check to ensure vulnerable people are suitably protected. The home has policies and procedures for safeguarding people in the home. Some staff have received training for recognising signs of abuse and reporting incidents others require this training. Presently there is no one living in the home who does not have capacity. However, the home must consider the need to have polices to support them when people do not have capacity; this is with regard to The Mental Capacity Act and Depravation of Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: Liberty Safeguards. The manager needs to ensure the staff are aware of The Mental Capacity Act Deprivation of Liberty Safeguards. All staff must be aware of their responsibilities and ensure there are no other less restrictive ways of keeping people safe and well if liberty is compromised. Decisions must always be in the persons best interests and assessments and questions must be satisfactorily answered. The home does have a restraints policy and behavioural management plans do refer to physical interventions. If this is deemed appropriate staff must be trained in this area, presently they are not. We were assured no restraint practices were used at the time of this inspection. We discussed how peoples money is protected and we are satisfied that effective systems are in place. Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable, homely, welcoming and safe environment. Evidence: Compton Care is spacious, safe, clean and homely; the home has aids and adaptations to suit the people who live there. All rooms are single occupancy, we understand that bedrooms have been personalised and are individualised to the people who use the service. People we spoke with hold a key to their bedroom. Cleaning products and other solutions are locked away reducing hazards to the people who live there. We found infection control procedures are in place, such as liquid soap, gloves and paper towel dispensers. All areas seen were well appointed, there is evidence to demonstrate people are involved with maintenance, daily living tasks and decisions about the home. We have asked the registered manager to ensure they are satisfied they meet with the Hygiene Code. Care Homes for Adults (18-65 years) Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures and training needs must be improved upon to fully protect the people who use the service. Evidence: During the time we spent at the home we spoke with staff and observed or heard them supporting people. We found there were very positive and engaging interactions between those people living at the home and the staff members. Staff tell us they feel valued and could talk with the management. People who live there told us they too like the management and are happy living there. One staff member said, The consistency is good, there is a good approach. I think what Richard and the proprietor have done is brilliant. Duty rotas were checked and we saw enough staff on duty to meet the needs of people who use the service, we can confirm the home has a consistent staff group. We looked at the files for two members of staff including the last person to be recruited. The new file contained an application form, one written reference, a health declaration, no identification and an application for an enhanced Criminal Record Bureau disclosure. Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: Two references and identification need to be in place. A supervision record should also be clearly documented until the CRB disclosure arrives. Staff members did have an Independent Safeguarding Authority (ISA) check which is the required check prior to the CRB. Not having all the documentation needed demonstrates staff have not been fully vetted prior to working with vulnerable adults. There is presently no training matrix in place and it was evident there are some shortfalls in training requirements e.g. Basic Food Hygiene, medication management, safeguarding of vulnerable adults. This should be sourced and provided as quickly as possible to demonstrate the staff have the skills and knowledge necessary to fully support the people who live there. Care Homes for Adults (18-65 years) Page 23 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is run in the best interests of the people who live there. Evidence: Compton Care was registered with the Care Quality Commission on 27/01/10. They can provide 24 hour care for five people with a learning disability. The registered manager, Richard Clarke and the registered provider James Smith were available during this key inspection. They have or in instances where there is a shortfall are undertaking training to ensure they receive all the information, knowledge and skills to run the home effectively and in the best interests of the people who live there. The Annual Quality Assurance Assessment was completed by the manager and it was returned to us within the agreed timescale. The annual quality assurance assessment (AQAA) is a legal document that all services have to complete on a yearly basis. The information was as detailed as it could be to demonstrate the service was based on robust and continual self assessment. All sections of the AQAA were completed and information gave us a clear picture of the service which was verified through the inspection process. Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: We saw and heard evidence to validate the manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. Quality assurance will be undertaken but presently it is too soon. The outcomes from the quality assurance surveys will need made available for people who use the service. We received confirmation that no finances or personal allowances are held for people who use the service by the home. Supervision of staff will be undertaken, again staff are new into post and presently completing their induction programme. All service maintenance records that we requested in the AQAA were up to date to show the environment is being safely maintained. We noted that fire hydrants are not fixed to the wall and this needs to be undertaken. We discussed individual fire risk assessments and advised the home to consult with the fire officer regarding this. We also advised the home to formally consider and record how each individual person would be evacuated in the event of a fire. We recognise Compton Care has only been operating with people living at the home for two weeks and they need the time to embed their policies, procedures, systems and structures. We can evidence that overall the service operates procedures that seek to ensure the quality of the service provided is good, and the people living there receive positive outcomes. Care Homes for Adults (18-65 years) Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 Regulation 13(2) 24/05/2010 The quantity of all medicines received and any balances carried over from previous cycles must be accurately recorded to enable audits to take place to demonstrate the medicines are administered as prescribed. This is to ensure that the audit trail for all medicines is seen and medicines are administered as prescribed at all times. All information required 01/06/2010 under Regulation 19(4)(b)(i) must be in place when recruiting new staff. This means the home can clearly demonstarte they have recruited people safely to protect vulnerable adults. 2 34 19 3 35 18 Regulation 18(1)(c)(i) Prioritised action must be taken to ensure essential 01/07/2010 Care Homes for Adults (18-65 years) Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action mandatory up to date training is provided for all staff commensurate to their role. This means all staff have the necessary knowledge and skills to meet the needs of the people using the service Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The Service User Guide should offer information about what people pay for regaring their support from staff. This means everyone has a clear understanding. Ensure that all written records are dated and signed, this means there is clarity for review and a named person to refer to, regarding the information recorded. The manager could introduce a professional visits form to offer a clear audit trail of which health and social care appointments have been attended or what appointments are due. Risk assessments should be tailored to individuals to clearly demonstrate how risk is managed. Continue to promote choice by using methods and aids suitable for the people who use the service. Seek professional advise to ensure the menu plan is nutritionally balanced and suitable for the needs of the people who live there. This means the home can be confident they are supporting people as well as they can. We recommend the home uses a professional visit record so the information is clearly visible with an audit trail to ensure appointments are undertaken when required. The records of administration for the people who use the Page 28 of 30 2 6 3 6 4 5 6 9 17 17 7 19 8 20 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations service need to be accurate to demonstrate that all medication is administered as prescribed. This is to ensure people are kept safe and records tally with actions. 9 20 Systems must be in place to ensure staff have details of when, how and why they are to administer as required medications. Comments and grumbles should be recorded to assist the manager in identifying any patterns or trends. The home could provide a suggestions, comments or complaints box which is easily accessible. This is so people may provide information anonymously if they so choose. To make sure people are safeguarded the service needs to ensure there are policies in place wth regard to The Mental Capacity Act deprivation of liberty safeguards. This is to make sure staff know what course of action to take, understand the assessment processes and are clear of their responsibilities. Policies and procedures need to be reviewed to ensure they contain all the information necessary. This means there are clear guidelines for the staff to follow. Speak with the fire officer to confirm the need for individualised fire risk assessments for the people who use the service. This means people will be suitably protected. 10 22 11 23 12 40 13 42 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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