Care Home: Compton Manor

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

What the care home does well People who are considering moving into the home benefit from having their care needs assessed so that they can be sure the home can meet their needs. The home had a very relaxed atmosphere and we saw that staff had good, friendly relationships with the people living in the home. Residents` individual religious beliefs and cultural preferences are respected and opportunities for religious worship are provided as requested. There is an open visiting policy and residents have the choice of where they entertain their guests so that they can meet in private if they wish. Two visitors told us: I have been visiting here every week and I am always made welcome" and "The girls are very hardworking, l can`t fault them". Residents` monies are managed in a safe and transparent manner. The home provides good choices for meals and people told us that the quality of the food is very good. One person said "I love the food, there`s always plenty to choose from". Complaints are taken seriously and always acted upon. Staff received regular training in Safeguarding and people should feel reassured they will be safe from harm in this home. The home had not had any complaints since the last key inspection There are sufficient staff on duty to meet the needs of the people who live there. Comments received from 2 people we spoke with include: "they come and help me immediately;" "there`s always someone about, you never have to wait long." What has improved since the last inspection? The manager and staff have worked hard in addressing the requirements and recommendations made at the previous inspection. This demonstrates the motivation of staff in ensuring that the services provided are for the benefit for those people who live at the home Care Plans contain information about the actions staff need to take to meet identified needs. An induction programme linked to the guidelines of the Skills for Care Council has been introduced. CARE HOMES FOR OLDER PEOPLE Compton Manor Compton Road Holbrooks Coventry West Midlands CV6 6NT Lead Inspector Patricia Flanaghan Key Unannounced Inspection 09:15 26 & 30th June 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Compton Manor Address Compton Road Holbrooks Coventry West Midlands CV6 6NT 02476 688338 02476 688338 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Vijay Odedra Jacqueline Lynn Greenwood Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Compton Manor is a care home for thirty older people, situated in the Holbrooks area of Coventry. Accommodation is located on the ground floor and first floor. There are 22 single bedrooms and 4 shared bedrooms with 5 of the single bedrooms having en-suite facilities. The first floor is accessible by a passenger lift. The home has two lounges and separate dining room on the ground floor with a small sitting room, used as an activity room, on the first floor. There are open plan gardens to the front and private gardens to the side. There is a regular bus service, which passes the home, to enable ease of access to local shops and the City Centre. Compton Manor is registered to provide care and accommodation for older people assessed as not requiring either specialist dementia care or nursing care. The range of fees charged at the home was not included in the service user guide. The manager told us the fees charged were £368.50 per week. Additional charges are made for hairdressing, toiletries, hairdressing and chiropody. Compton Manor DS0000067096.V367016.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 that people who use this service experience good quality outcomes The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. We made two visits the home on 26th June 2008 between 9.15am and 6:45pm and 30th June 2008 between 9.30am and 10:45am. The manager was present for the duration of the inspection. There were 23 people living at the home at the time of the inspection visits. We used a range of methods to gather evidence about how well the service meets the needs of people who use it. This included talking to people who use the service and observing their interaction with staff where appropriate. We also looked at the environment and facilities provided and checked records such as care plans, risk assessments, staffing rotas and staff files. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas where they believe they are doing well. Questionnaires were sent out to ten of the people living in the home as well as being distributed to relatives and staff during the inspection visit. We received four completed surveys from residents and two from relatives. Their comments about the service provided are included within this report. Two people using the service were identified for case tracking. This is a way of inspecting that helps us to look at services from the point of view some of the people who use them. We track peoples care to see whether the service meets their individual needs. Our assessment of the quality of the service is based on all this information, plus our own observations during our visit. At the end of the visit we discussed our preliminary findings with the home manager. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 6 We would like to thank the residents, relatives and staff for their hospitality throughout this inspection. What the service does well: What has improved since the last inspection? The manager and staff have worked hard in addressing the requirements and recommendations made at the previous inspection. This demonstrates the motivation of staff in ensuring that the services provided are for the benefit for those people who live at the home Care Plans contain information about the actions staff need to take to meet identified needs. An induction programme linked to the guidelines of the Skills for Care Council has been introduced. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 7 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. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. People who may use this service have good sources of information to make decisions about living there and benefit from having their care needs assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and a Service User Guide. Both of these documents give people the information they need to make choices about the service the home provides. We have recommended the home include the range of fees it charges people to live there. Once this is completed people thinking about using this service will have up to date information upon which to base their decision. Before people are admitted to the home the manager or a team leader visits the person to complete a pre admission assessment. This gives people to Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 10 opportunity to ask about the home and also for both parties to be sure that the home can meet their needs. We looked at the assessments for two people who had been recently admitted to the home and saw that they were detailed and gave good sources of information about the person. This means that staff are able to plan good care with people because they have all the information they need to do it. A signed ‘Condition of Residency’ was available in both files. These contained information about both the person’s and homes rights and fees payble. It also stated what further costs are required, such as hairdressing, chiropody and personal items. A recently admitted resident told us “My daughter visited the home and told me I would like it. I do, I think it’s wonderful here.” We spoke with a prospective resident and their relative who were visiting the home during the inspection visit. They told us they had been given information about the home and decided to visit to see if it was suitable. We saw a carer showing them around the home and noted they had been given a copy of the home’s service user guide. The manager also met with them to answer any questions they might have. This home does not provide any intermediate care service. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. People living in this home are treated respectfully and can feel confident that their health and personal care needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of our case tracking process we looked at the care records of two residents. Care plans are based on the assessment that is completed before the person moves into the home. Each person had care plans that reflected their individual needs. The care plans seen required the night staff to carry out hourly checks on each resident, but failed to identify why the checks were necessary or whether residents had requested them. Individual checks on residents should be based on the individual needs and circumstances identified during consultation with residents or if appropriate, their representatives. The reason for carrying out night checks should be noted in the care plan and any checks carried out Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 12 recorded on the daily records so that the home can be sure the care provided is as agreed on the care plan. The ‘psychological’ care plan for one person stated that ‘staff to give support to X when mood is low’ . There was no instructions on what actions that staff have no to take to take to minimise any distress the person may experience. Another person was identified as having ‘a fear of falling’ and having panic attacks as a result. Again there were no instructions of what action staff should take to minimise any distress. Care plans must be available for each of the identified needs of people to make sure that their needs are met. Nutritional screening is carried out when the resident moves into the home and the outcome of regular weight checks recorded. Risk assessments for the prevention of pressure sores and moving and handling were in place and a risk assessment for the prevention of falls was held for a resident assessed as being ‘at risk of falls’. Examination of the care files found people had regular access to GPs, district nurses, optician, chiropodist, and dentist and community psychiatric nurse. Residents requiring specialist equipment such as a pressure relieving mattress, cushion or hospital type bed have their needs assessed by the district nurse who also arranges for any equipment necessary to promote the health and well-being of the resident. The manager said none of the people living in the home were being treated for pressure sores. One person commented in the questionnaire returned to us: “ The home meet most daily needs but X’s personal hygiene is not as it should be. A shower or bath are infrequent and should be at least on a weekly basis.” We spoke with 4 members of staff who were able to demonstrate knowledge and understanding of the individual needs of the people in their care. Observations of staff practices found staff responded promptly and sensitively to the needs of people. The systems for the management of medicines in the home were examined. A monitored dosage (blister packed) system is used. Medication is safely stored in a locked trolley. The medication administration records are well maintained. There were no omissions on the records on all the records examined. Staff receive training in the safe administration of medicines. The home has a good system to check the prescriptions before dispensing and to check the medicine charts and medicines upon receipt. All controlled drugs (CD) currently in the home were correctly recorded in the CD register. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 13 Time was spent in the communal areas with residents and staff. People were cared for in a respectful manner and this ensured that their dignity and selfesteem were maintained. Conversations between staff and residents were respectful and observations of staff practices found that staff responded promptly and sensitively to the needs of residents. Terms of preferred address were on the person’s care plan and heard to be used by staff. All people spoken with were positive about the care they receive in the home. Comments received on the day include: • • • “I am very pleased with the care.” “All the people here, staff and residents are very caring. “The girls (staff) can’t do enough for you.” Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. People living at the home are occupied and stimulated and are able to make choices in their daily lives. Visitors are welcomed and residents enjoy the meals provided which are nutritious and varied. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents in the main lounge area were sociable and all appeared to get on well with each other. There were no rigid rules in the home and residents were free to come and go as they wish. Observations made and discussion with people showed that residents have the opportunity to make choices in their daily lives, such as when to get up and go to bed, what to eat, whether to join in activities or not and where to spend their time. Small pieces of furniture, pictures, ornaments and photos belonging to the occupants were seen in bedrooms showing that residents were able to bring personal possessions with them when they came to live in the home. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 15 People said that activities take place in the home and they have a choice whether they join in. There was a basic activities programme in place and residents had access to the range of additional activities provided by the staff in the day-care facility. The manager said residents were encouraged to participate in activities. Three residents spoken to said they were satisfied with the activities available which include: exercise therapy; sing along, a visiting library and board games. A record of activities undertaken and the people who participated is kept. However, there is no information recorded on whether the activity was enjoyed and what was done for those people who did not join in the activity. One person commented: “If I feel like it, I participate in activities, we are not obliged to join in. I can please myself.” Attempts at writing life histories for individual residents showed a lack of informative information. Developing life histories with residents and their families will give staff an insight into a person’s life to date and should help to meet their diverse needs. For example information gained may be related to what job the person did, what hobbies or interests they had/have and details about their family life. These details will provide staff with information to ensure that care and activities planned is person centred and will help them to look at the residents as individuals. The home has an open visiting policy. We had the opportunity to speak to two relatives during this inspection they told us “I have been visiting here every week and I am always made welcome” and “The girls are very hardworking, l can’t fault them”. Residents were observed eating their meal at lunchtime. The meals for the day were put on a menu board in the dining room. A person who lives in the home assists by laying the tables in preparation for lunch. It was apparent that they enjoy doing this and considers it to be ‘their job.’ Three choices of hot meal are available and further alternatives are available if the residents do not want what is on the menu for that day. Snacks are available throughout the day. The home is able to cater for special diets for reasons of cultural or medical needs. As there are a large number of residents of Asian origin in the home, there is always an alternative of a curry normally vegetarian with rice and a chapatti. People spoken with were satisfied with the food being served to them. We were told; I look forward to my meals, and “you can’t fault the food.” We saw people were offered ‘seconds’ by staff, which is good practice. There was a choice of drinks offered at mealtimes and beverages were provided throughout the day. Care staff were available to assist with the meal and any support required was given sensitively and discreetly. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. People living in the home can be confident that their concerns will be listened to and acted upon. There are systems in place to respond to suspicion or allegations of abuse to make sure people living in the home are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints policy that is on display in reception area. The manager told us in the AQAA: “We have an effective complaints procedure within the home. We have an updated complaints policy and both service users and staff know how to make a complaint. Service users and staff are confident that when a complaint is made that it will be fully investigated and a written response received immediately.” The home has received no complaints in the last 12 months. Residents spoken with said that they had no complaints about the home and enjoyed living in the home. They felt that they could report any matters or concerns to the manager or care staff and these would be dealt with. Comments received included: Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 17 • • “I’ve no need to complain” “I haven’t needed to make a complaint, but I would talk to one of the staff” These comments suggest that residents know how to make a complaint and feel confident that their views would be listened to. The home has appropriate policies in place for dealing with safeguarding issues. Staff can also raise issues using the homes whistleblowing policy. Staff continue to have training in Safeguarding issues and the home has a rolling programme of training to make sure all staff do this. This will ensure that staff are aware of the signs of abuse and what to do if an allegation of abuse is disclosed to them. The manager demonstrated during discussion that she is aware of local Social Services and Police procedures for responding to allegations of abuse. Discussions with two members of staff demonstrated that they are aware of their role and responsibility in reporting any suspicion of, or actual harm to residents. The home also makes sure that when recruiting staff it completes the required safety checks against the Protection of Vulnerable Adults list (PoVA) and Criminal Records Bureau (CRB). These checks help to prevent unsuitable people working with vulnerable adults. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is adequate. People live in a pleasant and comfortable environment, which is clean and generally well maintained to ensure residents can be cared for safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home was undertaken with the manager. We were able to go into all areas of the home, including some personal rooms and all communal areas and the gardens. There are two lounges, an activities lounge and a dining room available in the home. The home was clean, bright and tidy. The gardens are well maintained and garden furniture is available for the residents to sit out if they wish. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 19 A number of bedrooms were viewed. It was evident that residents are encouraged to personalise their rooms with their own items such as photographs or soft furnishings. One person told us, “I love my room, it’s home from home.” The manager told us in the AQAA: “The home has just benefited from a new fire alarm system. Several rooms have received new carpets. The lounges have been newly decorated and curtains purchased. New chairs have been purchased and activities material has been purchased including a new flat screen television.” Some of the corridors are rather narrow, and there is a general need for decoration in a number of areas around the home. The walls and doors in some of the corridors would benefit from being painted or wallpapered, as some walls were grubby. The manager told us that there is a rolling programme of redecoration and refurbishment in place so that people are provided with an attractive and comfortable place to live. The home provides equipment necessary to assist residents to maintain their mobility and independent access around the home. Grab rails are positioned throughout the home. Zimmer frames, tripod walkers and walking sticks were seen in use and residents moved around the home safely The home has good systems in place to manage infection control. The laundry in the home is adequate to meet the needs of the residents and the size of the home. It was clean and well organised with a number of health and safety procedures displayed. Staff have access to gloves and aprons, all communal toilets and bathrooms have liquid soap and paper towels. These measures will help reduce the spread of infection to residents. Staff are also having training in infection control this will help to keep their knowledge and practices up to date. The kitchen was clean and tidy on the day of the inspection. One person commented in the questionnaire returned to us: “The home is usually clean, but sometimes smells linger, for example, cooking smells and stale urine.” Another person said “General décor of the home could be improved.” Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. There are sufficient numbers of staff on duty at all times to meet the needs of the people who live here. Staff are recruited safely and are given training to ensure they are competent to do their jobs . This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw from duty rotas and the numbers of staff on duty at the time of inspection that there were sufficient staff to meet the needs of residents accommodated in the home. The acting manager confirmed that the usual staffing complement for the home is: 8.00am – 3.00pm 3.00pm – 10.00pm 10.00pm –8.00am 1 Senior Carer in charge supported by 4 Care Staff 1 Senior Carer in charge supported by 3 Care Staff 3 care Staff The home employs 17care staff, 14 of them have achieved their National Vocational Qualification (NVQ) level 2 in Health and Social Care, while the other 3 are working towards this qualification. This means that staff will have Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 21 gained the knowledge they need to build on their skills and provide care to the people living in the home. The personnel files of two recently recruited staff were examined and both contained evidence that satisfactory checks such as Criminal Record Bureau (CRB), Protection of Vulnerable Adult (PoVA) and references are obtained before staff commence employment in the home. Robust recruitment procedures and pre-employment checks should protect the vulnerable people living in the home. New staff have an induction period and evidence available showed that induction training for new staff is linked to the ‘Skills for Care’ induction programme. We were able to speak to new workers during the inspection about their experience and the support they felt they were being given. A carer told us that they felt supported by both the manager and deputy during their induction. Staff training records demonstrate that staff receive mandatory training including fire safety, abuse awareness and moving and handling. Training arranged for staff in the coming months include; Infection Control, Care Planning and Report Writing, Equality Diversity and Rights and Pressure Care Awareness. Comments received in questionnaires completed by visitors to the home include: “I feel that friendly, helpful staff is the best asset of this home,” and “the care and attention the girls give to each resident is wonderful.” Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The manager is competent and fit to be in charge of the home. Appropriate policies and procedures offer a sound framework and safeguard peoples’ interests and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager had been at the home for approximately six months and is suitable qualified and experienced to manage a service of this type. She has completed NVQ4 in care and the manager’s award. She has also undertaken training throughout the year to update and further improve her knowledge and skills. She was present throughout the inspection and was knowledgeable about the people using the home. Staff and residents spoken with said that she Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 23 was approachable that they felt supported by her and that they were able to talk to her if they had any concerns. Visitors spoken with also spoke highly of her and her management of the home. There had not been any progress with implementing a formal quality monitoring system in the home. The manager had undertaken room audits and food audits with people living in the home. The manager also undertook other audits within the home, for example, medication audits and health and safety audits. However there was no way of analysing the information gathered and drawing up a yearly development plan for the home with the aim of continually improving the service. Although we were told that the provider was a frequent visitor to the home there was little evidence that he was making any unannounced visits to the home to oversee the management/conduct of the home. It is an ongoing requirement that these visits take place and that the proprietor inspects the environment, samples administration and speaks to the people living in the home and then prepares a report on the outcome of the visit. Systems for the safe keeping of monies to safeguard residents’ financial interests are good. Records seen are appropriate and receipts and written records of transactions are kept. Information provided by the manager on the AQAA shows that the home has undertaken the required safety checks related to electrical and gas installations, portable appliances, hoists and other equipment. A random check was carried out on maintenance, servicing and health and safety checks, which included in-house fire safety checks. These were in good order and staff had undertaken mandatory health and safety related training, indicating that the home was a safe place for people to live and work. Chlorination of water and testing for the prevention of Legionnaires has been carried out and a copy of the report shared with us. Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 24 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 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 X 2 X 3 X X 3 Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 12,13 Requirement Care plans must be available for each of the identified needs of residents. This is to make sure that people’s identified needs are met. Timescale for action 30/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP7 Good Practice Recommendations The details of the range of fees charged should be included in the service users guide, for people’s information. The need for night checks on service users should be based on the individual’s needs and circumstances and agreed with the service user, and or if appropriate, their representatives. The reason for carrying out individual night checks on each Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 26 resident should be included in the care plan and any checks carried out recorded on the daily records. 3 OP12 The manager should consult with the people living in the home about the range of activities available to them and arrangements made to ensure their individual social needs are met. The home should continue the refurbishment programme for those areas needing attention, for example, worn carpeting, shabby wallpaper on corridors, chipped paintwork to stairs, door frames and skirting boards. This will ensure that people who use this service live in clean and pleasing surroundings. The responsible individual needs to conduct unannounced monthly visits and supply a written report to the manager. This means the responsible individual is able to form an opinion of, and monitor the standard of care provided at the home. The home must have a system in place for monitoring the quality of the service offered based on seeking the views of the people living in the home with a view to continuous improvement. This will ensure the service offered in the home is kept to an acceptable standard for the people living there. 4 OP19 5 OP33 6 OP33 Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Compton Manor DS0000067096.V367016.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!