Care Home: Compton House

What has improved since the last inspection? Improvements to the environment since our previous visit include the provision of a quiet room that can be used by staff, people living in the home or visitors, and the re-carpeting of the hallway, ground floor corridors and stairs. There has also been refurbishment to the kitchen and main lounge. An activities co-ordinator has been employed and this has helped provide a wider range of activities and to better ensure that people`s interests and hobbies can be encouraged and their social needs met. Some new medication storage has been provided which is helping ensure safer storage of medicines. There have been some increases in staffing numbers at busy times. Seven staff have completed National Vocational Qualification level 2 training. What the care home could do better: We found there to be a lack of records to show that staff were receiving regular one to one sit-down supervision support. Key inspection report CARE HOMES FOR OLDER PEOPLE Compton House 40 Compton Road Lindfield Haywards Heath West Sussex RH16 2JZ Lead Inspector Ed McLeod Key Unannounced Inspection 11th May 2009 09:30 DS0000024131.V376069.R03.S.do c Version 5.2 Page 1 This report is a review of the 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. 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 older people 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. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Compton House Address 40 Compton Road Lindfield Haywards Heath West Sussex RH16 2JZ 01444 482662 01444 487830 jennie@lcchome.co.uk 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) Lindfield Christian Care Home Mrs Jennifer Herring Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 27. Date of last inspection 15/05/07 Brief Description of the Service: Compton House is a care home which is registered to accommodate up to twenty seven residents in the category (OP) old age, not falling within any other category. It provides personal and nursing care. Compton House is a detached two storey property which provides accommodation in two shared and twenty three single bedrooms located on the ground and first floors. A vertical passenger lift provides access to all floors. A dining room and lounge are located on the ground floor. The property is located in the village of Lindfield. The fee levels range from £665 to £815 per week. Additional charges are made for the following services: chiropody, hairdressing, dentist, optician, telephone, and newspapers. The registered provider is Lindfield Christian Care Home, who have appointed Mrs Christine Corbett Taylor to be the Responsible Individual and to supervise the overall management of the care home. The post of registered manager, who is responsible for the day to day running of the care home, is Mrs Jennifer Herring. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 5 Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. The visit was arranged to assess the services compliance with the Care Homes for Older People key national minimum standards. In preparation for this visit we looked at the information we have received or asked for since our previous visit and this included: The annual quality assurance assessment (the AQAA) which was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service What the service has told us about things that have happened in the service The previous key inspection and the annual service review reports During this visit we spoke with six people living in the home, with five members of staff, the manager, and the responsible individual for the service. We sampled the pre-admission assessments for three people living in the home, and care plans for four people living in the home. Other records we looked at included some records relating activities provided, the management of medication, health and safety and complaints. We sampled recruitment records for three members of staff, training records for seven staff, and supervision records for four staff. What the service does well: The home is managed well and has a relaxed and friendly atmosphere. A good standard of care is being provided, and there is a choice of activities in which people can take part. The home has good and established links with the local community. The home is clean and comfortable and is furnished and decorated to a good standard. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: 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. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 3, 5 People using the 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 are confident the 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 and the support they need. EVIDENCE: The homes annual CQC quality assurance assessment (the AQAA) tells us that a detailed Statement of Purpose and Service User Guide is available for all new residents prior to their admission. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 10 The AQAA tells us that prospective new residents are visited and assessed by the registered manager or the deputy manager and that new residents are admitted only if the service believe they can meet the persons needs. We looked at three written assessments the home had completed with people before they were admitted to the home. Assessments seen included an evaluation of the persons care, health and social needs. There was also an admission checklist to ensure that people are helped to settle in and be provided with everything they need when they first come to live in the home. The manager, Mrs Herring, told us that new residents are admitted on the understanding that there is an initial trial period, and that potential new residents are encouraged to visit the home with family members prior to admission if possible. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 7, 8, 9, 10, 11 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If people cannot manage their medicine the care home supports them with it in a safe way. Peoples right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 12 EVIDENCE: The manager tells us in the AQAA that each resident has their own care plan, written by their named nurse and the registered manager, and that the person and/or their family or representative contributes to this. The AQAA tells us that care plans are reviewed monthly and that risk assessments are undertaken monthly for safety, falls, skin integrity, nutrition and manual handling. We looked at parts of four sets of care plans, and found that care plans were being regularly reviewed and that risk assessments were being updated – for example one persons risk assessment had been updated after they had had a fall. The new assessment considered action that could be taken to prevent further falls. We found that care plans were including some information on how people wished their care to be provided. A member of staff has also recently compiled a list of the drinks people usually prefer in the evening and how they like them prepared. A member of staff we spoke said to us that they had always felt that the people home were receiving the best possible care and that the care provided in the home had never been poor. Staff we spoke to told us that people usually have a bath or shower twice a week, and a full wash each day. All the people living in the home who we talked to during our visit looked well cared for and had no concerns about their care. The AQAA tells us that eight people accommodated have dementia care needs. During our visit the manager Mrs Herring indicated that people with dementia care needs were not being admitted to the home, but that some people living in the home have subsequently developed dementia care needs. We asked the manager Mrs Herring how the home is meeting the needs of people with dementia. She told us that ten staff have commenced a distance learning course in dementia and that the course is assisting staff in recognising and meeting peoples health and mental health needs. Mrs Herring said she was trying to ensure that each shift has someone who has undertaken some dementia Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 13 training. The AQAA tells us residents are able to register with the GP of their choice or to remain with their own GP if appropriate. All residents are given the opportunity each year to have the flu vaccination and that this is administered during a GP visit by the GP or qualified nurse. We are told in the AQAA that people living in the home are enabled to access sight and hearing tests, chiropody, physiotherapy, and district nursing services, and that if residents have a hospital appointment and their family are unable to attend with them a member of staff will attend as an escort to provide support. The manager tells us in the AQAA that medication is only dispensed by registered nurses, and that on initial assessment the home discuss with new residents if they would wish to hold and administer their own medicines. If they wish to do this the home risk assess this and discuss with their GP. Staff we spoke told us that no-one in the home had opted to hold their own medication. During our visit we found that the medication system has been improved by new medication storage arrangements. The member of staff responsible for checking and ordering medication told us they attend with the GP when he does his weekly visit, and that the GP reviews each persons medication each week. We found that arrangements for the administration and disposal of controlled medication were in place. The AQAA tells us that staff are discouraged from entering rooms unnecessarily during the morning when personal care is being given, and that notices are placed on every door reminding staff and visitors to knock before entering residents’ rooms. We are told in the AQAA that residents’ rooms are viewed as their home, that residents are able to entertain their visitors and any professional person or advisor who comes to see them in privacy, and that all rooms have a telephone line. The interactions we observed between staff and people living in the home indicated to us that peoples privacy and dignity are being respected. We Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 14 noted that there was a please knock before entering notice on each bedroom door. The deputy manager told us that the Liverpool Care Pathway provides the methodology in the home to provide care when people are nearing the end of life. Examples were given by staff of the support offered to the person and their family when end of life of care is provided. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 12, 13, 14, 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability and sexual orientation. They 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. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks at a time and place to suit them. EVIDENCE: Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 16 The manager told us that the employment of an activities co-ordinator has helped provide more of the activities that people enjoy and wish to take part in, such as music and reminiscence. During the day of our visit activities taking place included a performance of popular songs by a guitarist and singer which was well attended and many people were seen to be enjoying themselves and singing along. The AQAA tells us that the activities co-ordinator talks with people about the things they enjoy and will then develop a personalised plan of activities with them. Care records seen told us that, during the month of April for example, one person had attended three musical performances, an exercise class, two film showings, three Christian readings groups, and had one to one social time with the co-ordinator on two occasions. We found at our visit that there is an established team of volunteers who visit the home regularly and that they help, for example, with maintaining the garden and providing afternoon tea. The AQAA tells us that volunteers can carry out errands for residents, assist with organised outings taking residents on organised outings in the summer months. No charge is made to residents for this. A brochure for the home tells us that in 1992 the three churches in Lindfield established Lindfield Christian Care Home as a Christian home open to all. The manager told us that volunteers from local churches conduct Christian services on Wednesday and Sunday mornings, and a pastoral visitor can visit residents if requested. There is a programme of weekly activities within the home including an art class, musical exercises, a visiting ‘PAT’ dog, various outings and entertainers who come into the home – a monthly calendar of events is published and copies of this were seen on display in communal areas and in peoples bedrooms. People living in the home who we talked to told us that they are being offered activities they enjoy, and that one to one activities such as manicures are popular. People told us they have a choice of whether or not to take part in things. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 17 The home is very much involved with the local community through its volunteer programme and encourages people to remain in contact with their families and local community. For example, the weekend previous to the visit a plant sale had taken place at the home which one of the people who had helped run it said had been very successful. Meals can be taken by residents as they wish in the dining room, the lounge, the garden (weather permitting) or in their own room. The AQAA tells us that the catering manager meets new residents to discuss their particular likes, dislikes and needs. Menus are available for residents to see and comment on in the dining room. The menu is available in large print at reception, and residents may have their own copy if they wish. We observed the lunch being served during our visit. We noted that people who needed assistance with eating and drinking were receiving this in an unobtrusive and unhurried manner. People we spoke to during the lunch told us there was a good choice of meals, and that if you wanted something not on the menu instead this was provided. For example, on the day of our visit had requested fish and another person requested a cheese sandwich instead of the menu choices, and had received their choice. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 16, 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people have concerns about their care they or other people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. EVIDENCE: The AQAA tells us that the home has a clear written complaints procedure which is contained in the Service User Guide which is given to all new residents and is displayed at reception, on the residents’ notice board and in every residents’ room. Bedrooms we visited had a copy of the complaints procedure on view. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 19 We looked at the complaints record which had one complaint recorded during the past year. The record indicated that the issue had been investigated, there had been meetings with the complainant and action taken, and the complainant was satisfied with the outcome. The AQAA tells us that policies are in place to protect residents from all forms of abuse, and that the policies are supported by staff receiving training once a year in safeguarding adults. The manager told us that she had attended a recent briefing with the local county council on local safeguarding procedures including raising alerts, and that the briefing has been discussed with staff during a staff meeting. We noted that the service was holding a copy of local safeguarding procedures. The AQAA tells us that people who are able are encouraged to manage their own financial affairs. A policy and procedure is in place if the registered manager holds a resident’s personal money. We were advised during our visit that the service was not at that time holding amounts of money for any person living in the home. The manager told us that staff are being made aware of the Mental Capacity Act and the deprivation of liberty standards and that training for staff was being set up in these topics. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 19, 21, 24, 26 People using the 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 stay in a well-maintained home that is homely, clean, 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. Their rooms feel like their own, it is comfortable and they feel safe when they use it. EVIDENCE: Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 21 During this visit we found that the home environment and outside areas are being maintained to a good standard, and that an ongoing programme of renewal, refurbishment and re-decoration is in place. Improvements to the environment since our previous visit include the provision of a quiet room that can be used by staff, people living in the home or visitors, and the re-carpeting of the hallway, ground floor corridors and stairs. There has also been refurbishment to the kitchen and main lounge. A system is in place for alerting the maintenance team to any maintenance issues which need attending. We looked at some maintenance records and these indicated that maintenance issues are being recorded and dealt with in a timely manner. We found toilet and bathroom facilities to be of a good standard, and facilities include disability baths and wet room shower areas. Hot water temperature records of baths and showers are being maintained. The AQAA tells us that disability aids are provided as needed, and that wheelchair access is available to all areas of the home. A loop system is in place to allow people with hearing problems to better hear television programmes. We visited six bedrooms and found them to be well furnished, uncluttered and and that people had brought personal possessions, items of furniture and pictures for the walls to personalise their rooms. During our visit we visited a vacant bedroom which had been re-decorated and re-carpeted, and the AQAA tells us that this is always done when a room becomes vacant. The AQAA tells us that fully adjustable and specialist beds which assist in the management of pressure areas are provided, and that each resident has their own lockable cupboard. We visited one of the shared bedrooms in the home, and the manager gave examples of how the privacy and dignity of people sleeping in shared bedrooms is maintained. All areas of the home visited were found to be clean and free from odours. We visited the laundry room and found arrangements were in place for the washing of soiled linen. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 22 Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 27, 28, 29, 30 People using the 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 have safe and appropriate support as there are enough competent 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 to care for them. Their needs are met and they are cared for by staff who get the relevant training. EVIDENCE: The AQAA tells us that staffing numbers have been increased for the shifts 9.00 a.m. to 1.00 p.m. and 5.00 p.m. to 9.00 p.m. as these are times of the day when more personal care needs to be provided. Staff we spoke to during our visit told us that the increase in staff at these times has been helpful. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 24 The manager tells us in the AQAA that there is a very stable team of qualified and care staff with a back up from a ‘bank’ of staff who are well known to the residents. The AQAA tells us that agency staff are very rarely used. and only if the shift has not been covered by the permanent staff team. We spoke with two members of staff about staffing levels, and they said that they believed there were enough staff on duty at all times to meet peoples needs. The AQAA tells us that references and criminal records bureau and protection of vulnerable adults list checks are undertaken with all employed and volunteer staff before they have unsupervised contact with people living in the home. We sampled the recruitment records and staff rotas for three people employed in the home during the past year and found that the required checks and references had been obtained before the member of staff had worked an unsupervised shift. The AQAA tells us that common induction standards training is provided for all new staff, and staff records and rotas we sampled for three people employed within the past year indicated that they were working supernumerary shifts and receiving induction training during the first weeks of their employment. The AQAA tells us that monthly training days are held to include all mandatory training requirements, including DVD-based training in topics such as safeguarding vulnerable adults and food hygiene. We are told in the AQAA that external trainers are used for Infection Control and First Aid training. The AQAA tells us that twelve staff have NVQ 2 qualifications, two staff have NVQ 3, and that four care assistants are qualified in nursing in other countries. During our visit we discussed with the manager the ASET level 2 certificate in dementia care which ten staff including the manager and deputy manager are undertaking. The manager said that this training was helping staff to better assess and meet the dementia care needs of people living in the home. A member of staff we spoke to told us that the training on dementia was really interesting and was helping explain why people were behaving in a certain way. We sampled training records for seven members of staff, three of whom had been employed in the past year and four of whom had been working for the Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 25 home for a longer period of time. We found that arrangements for appropriate training for care and for nursing staff were in place and ongoing. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP31, 32, 33, 35, 36, 38 People using the 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 have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 27 EVIDENCE: Mrs Jennifer Herring was registered as manager for the service in October 2008. In the AQAA, she tell us that she has continued to update her knowledge and skills by attending training in topics such as end of life care and care for people with dementia. During our visit one person living in the home told us that the manager was very good. She knows all of us. Surveys have been carried out to obtain from relatives and people living in the home their views on the service provided. Suggestions made in the surveys and in relatives and residents meetings have been put in place – one example being a board which shows the photograph and name of staff on duty. We are told in the AQAA that a procedure is in place with regard to handling a residents money if this proves necessary, which is audited monthly. We were advised during our visit that the service was not at that time holding amounts of money for any person living in the home. The AQAA tells us that residents have access to their own lockable cupboard for all valuables or to the safe if necessary, and records are kept where items have been placed in the safe. People living in the home and staff who we talked to said there was a good atmosphere in the home. We discussed arrangements for staff supervision with the manager and the deputy manager. They told us that each of the trained nurses in the home is responsible for providing sit-down supervision for a number of care staff, but that as many care staff are part-time and some may work only one shift per week it was difficult sometimes to find the time to provide supervision. During our visit the deputy manager told us that supervision sessions helped encourage staff to discuss their training and development needs and give the staff the opportunity to talk about work issues. We asked the deputy manager what training nurses were receiving in providing supervision and were advised that this is usually covered during a study day. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 28 We asked to see the supervision records for four members of staff. For three of the staff there were no supervision records available covering the past two years. For one member of staff the most recent supervision record was dated March 2007. A requirement has been made concerning the need to provide and record supervision for staff. The manager has advised us in the AQAA of the most recent equipment services or tests which have been carried out, and that hazardous substances assessments are in place. Training in health and safety topics, including manual handling, food hygiene, fire safety, first aid and infection control are being provided for staff. We visited the kitchen and talked with the chef. We found that a food management checklist and cleaning checks were in place, and that fridge and freezer temperatures recorded were within the temperature ranges the service was seeking. The chef told us that the Safer Food Better Business system for food safety checks had recently been obtained by the service and was to be implemented. All accidents and incidents are recorded and monitored and followed up by the Manager or her Deputy. We noted on one care file that the risk assessment had been updated after an accident had taken place. In the AQAA we are told that fire safety is maintained by the Health and Safety Manager who undertakes risk assessments, fire drills and organises fire training for all staff. We looked at the record of monthly safety checks carried out in April 2009. We found that monthly safety checks including environmental safety checks are being carried out in the home. Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? no 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 OP36 Regulation 18 (2) (a) Requirement The registered person shall ensure that all persons working at the care home are appropriately supervised. We found that records for the supervision of staff were not evidencing that regular one to one sit down supervision was taking place with staff. Standard 36 recommends that care staff receive formal supervision at least six times a year and that supervision covers all aspects of practice, philosophy of care in the home, and career development needs. Timescale for action 28/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 31 Compton House DS0000024131.V376069.R03.S.doc Version 5.2 Page 32 Care Quality Commission The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT National Enquiry Line: 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. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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