Inspection on 17/10/06 for Scott House

This inspection was carried out on 17th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Scott House 16/10/07

Scott House 08/12/05

Scott House 18/07/05

Scott House 10/01/05

Scott House 16/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Scott House 7 Warham Road South Croydon Surrey CR2 6LE Lead Inspector David Halliwell Key Unannounced Inspection 17th October 2006 09:30 Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scott House Address 7 Warham Road South Croydon Surrey CR2 6LE 020 8686 9312 020 8668 3212 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) Laurel Residential Homes Limited Nina Harman Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user over the age of 65 to be accommodated. 8th December 2005 Date of last inspection Brief Description of the Service: Scott House is a large traditional brick built property situated to the south of Croydon, but close to the towns many community facilities. The house consists of a large lounge with open plan dining area and a conservatory. There are 15 single bedrooms and 3 double - none has en-suite facilities other than wash hand basins. There are 8 toilets, 3 bathrooms and 2 showers. There is a garden to the rear and off-road parking to the front. The stated aim of the home is to provide care for people with long term mental health problems. The average fee for a placement at Scott House is £590 per week. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit undertaken by the new Inspector responsible for Scott House. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 3 staff and the Registered Manager. 4 service users were spoken with formally and more informal interviews were conducted with 3 other Service Users as a part of the tour of the home. 3 new requirements have been made as a result of this inspection and 2 previous requirements have been partially met. Feedback on these requirements and recommendations was given verbally to the Manager and to one of the Proprietors at the end of the inspection visit. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was impressed by the commitment and enthusiasm of the Manager and of the staff group. The Manager informed the Inspector that the standard fees for a standard residential placement at this home are £590 per week. What the service does well: What has improved since the last inspection? Positive steps have been taken to meet the previous 3 requirements which were made after that inspection. The first was to do with staffing records, which has now been met; the second to do with supervision which has been partially met and the third to do with the development of the quality assurance process which has also been partially met. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 6 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. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 5. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users needs are being assessed by the staff at Scott House however these needs would be better informed if the referring agencies supplied more comprehensive and detailed information at the point of referral. Not all service users have an individual written contract or statement of terms and conditions with the home. EVIDENCE: Standard 2 – 7 of the current 18 service user files were inspected over the course of this inspection. For each service user an assessment of needs had been completed together with a risk assessment by the staff at Scott House. These assessments cover the service users essential needs. The review of these files included the last service users to have been admitted to the home. Assessment and care planning information supplied by the referring agencies was not evident on the files and the Inspector has recommended that the Manager should always request full documentation from referring agencies at the time of their requesting a new placement. This would ensure that staff at Scott House have all the available information about a prospective resident at an early stage of the process and would enable a fully Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 9 informed decision to be made about whether and how best a service users needs could be met. Standard 5 – From the inspection of files not all service users had a written contract for the service they are receiving at Scott House. As some of the service users had been transferred from another of the Laurel Homes Group they did have a contract relating to those services. However it is recommended that the Manager ensure that each resident at Scott House does have a written contract signed and dated by each party which covers all the requirements set out in Standard 5.2 of the National Minimum Standards for adults (18-65). This would ensure that the service users have a written and costed statement of the terms and conditions to do with the services they receive. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users cannot be fully assured that all their assessed and changing needs are reflected in their individual care plans. Service users are enabled to make decisions about their lives with assistance as needed and they are supported to take risks in order to maximise their independence wherever possible. EVIDENCE: Standard 6 - As already stated above the Inspector reviewed 7 residents files and found evidence of individual plans having been drawn up and reviewed for each of these residents. The stated purpose of Scott House is to provide long term care for the residents who have complex and long-term mental health problems. With this in mind the service user plans and the associated care plan objectives should be structured to take these factors into account. This said the plans were not as comprehensive in their detail to do with health and social care as would be expected. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 11 Of the files reviewed it was clear to the Inspector that whilst some key areas of need are being addressed in the plans other areas of need, which would assist in ensuring the unit’s objective of providing a comprehensive long term care for the residents was not being evidenced in the care plans. The development of care planning was discussed in full with the registered Manager and one of the Proprietors who have agreed to develop this detail in the care plans for each of the residents. All of the information required in schedule 3 of the Regulations was seen by the Inspector to be documented on the files. The 4 residents interviewed by the Inspector all said that they had been involved in the drawing up of their individual care plans. All residents interviewed felt that they had been properly consulted as to their own views and wishes about the care they receive but this information needs to be recorded in the detail of their care plans in a way that evidences their involvement and input. Individual care plans are regularly reviewed both within the home by the key workers and the co-workers with the residents and every 6 months with the referring agencies and other key people involved with the service users plan. Regular residents meetings are held within the home and there is an opportunity for residents to make their views known about relevant topical issues. Standard 7 - Service users informed the Inspector that they are enabled to make decisions about their lives with assistance as needed. Over the course of this inspection this was also evidenced to the Inspector through the exchanges seen between staff and the residents where staff were clearly respecting where appropriate residents to make their own decisions. Standard 9 – Risk assessments were seen on each of the files reviewed as a part of the initial assessment and care planning undertaken by Scott House. These assessments were seen to support the residents to take acceptable risks in order to maximise their independence wherever possible. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users have opportunities for personal development but this could be expanded with the fuller development of the care planning tools. Service users are enabled to take part in culturally and appropriate activities. They are also encouraged to take an active part in the community. Service users maintain appropriate personal relationships as they wish and staff do respect their rights and responsibilities recognised in their daily lives. Service users are offered a healthy diet which they enjoy. EVIDENCE: Standard 11 – Interviews with service users and inspection of the service users care plans identified that opportunities for the personal development of service users could be expanded. It is a requirement that care plans include Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 13 more detailed objectives, which could expand the range, and scope of service user’s life’s to include health and social care objectives. Standard 12 - The Inspector did not find any evidence that indicated whether or not residents were involved in activities which they did before they entered the home. There was evidence that support staff appropriately encourage the maintenance of resident’s relationships with family and friends if residents also wish to do so. Visitors to the home are encouraged and use the visitor’s book to sign in. Residents are enabled to take part in age and culturally appropriate activities by the support staff but only occasionally choose or feel able to do so. Standard 13 - Interviews with residents demonstrated that their wishes for an active community social life are limited and although staff do try to encourage residents to be involved as much as possible in local activities there is not a huge take up of these opportunities. Some residents told the Inspector that they like to go to the shops. One resident goes to church every Sunday and several residents use a local café where they meet other local people. Service users can and often do make full use of local public transport facilities in order to get out and about and to see friends and family. Residents interviewed felt that transport facilities were good. The Manager informed the Inspector that all residents are registered to vote in elections and are supported by staff to do so if they wish. However staff interviewed by the Inspector also reflected the difficulty in encouraging and motivating some residents to take an active part in this and other activities. The Inspector saw information made available within the home about local activities for residents to take up if they wish. Standard 15 – Some of the service users interviewed by the Inspector told him that they do keep in regular contact with their families and friends. One resident said that he sees his parents every weekend and that he enjoys the regularity of this contact. Staff encourage the residents to keep and maintain contacts with family and friends so that service users do benefit from having these appropriate relationships. Standard 16 - Policies seen by the Inspector to be established within the unit ensure that service users rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 14 Interviews both with staff and residents confirmed that residents participate in household chores as a part of the community living experience. There is a specific area for smokers and there are appropriate policies regarding drug and alcohol taking on the premises. Standard 17 - With regards to meals and meal times there is a planned and varied menu which residents told the Inspector they enjoy. The Inspector saw suitably planned menus for 3 weeks ahead. Specific needs are catered for and alternative choices are provided. Residents are able to state their preferences when the menus are planned and there are discussions about this at the residents meetings, which are held regularly. The Manager informed the Inspector that some residents are involved in the purchasing of the food and with the preparation of some meals. On the day of the inspection it was shopping day and the residents involved told the Inspector themselves that they thoroughly enjoyed going out to get the provisions with staff. Food monitoring sheets are in use for residents in order to monitor and ensure that they do have a varied and nutritious intake of food each week. However recording on these sheets is seen to lack sufficient detail. This has been discussed in full with the Manager and the Proprietor. It is a requirement to record what each resident has actually consumed and to look at this in the context of his or her healthcare needs. Where in some cases residents do have a healthcare need which requires a reduction in fatty and high in cholesterol foods the food monitoring sheet should prove helpful and will assist in positive action being taken in order to assist in reaching the care plan objective. Working together with the residents GP and dieticians should also be considered where appropriate. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be assured that they will receive personal support in the way they prefer and require. They may also be assured that their physical and healthcare needs will be met although recording in care plans needs to be further developed. Service users can be assured that they will be protected by the homes policies and procedures for dealing with medication and medicines. EVIDENCE: Standard 18 - Residents interviewed confirmed to the Inspector that they felt supported by staff in a way they prefer and require, the further development of care planning would assist expansion of this support. Residents confirmed that they have a choice when they get up, what they do during the day and when they do it. Residents told the Inspector that they do take a part in the household chores and are allocated responsibilities, which their key worker supports them with. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 16 Standard 19 – From the inspection and review of service user files it was not evident that healthcare needs are comprehensively planned for in the care plans for residents. The Manager informed the Inspector that healthcare needs of residents are assessed and reviewed regularly but acknowledged that they should be included as a part of the care planning process. This was supported by evidence on resident’s files. All service users do have access to the full range of healthcare professionals thereby ensuring that their needs are being met. Resident’s health checks are usually undertaken by the GP at their surgeries. An optician regularly visits the home and provides eyesight checks for all residents and there is access for residents to the chiropody services. Community nurses also visit residents at the home and administer medication as required. Standard 20 - Appropriate medication records were seen and reviewed by the Inspector. All the MAR sheets were properly completed by staff. Photographs of residents are included with the MAR sheets and this ensures that medication is only administered to the right resident.The Manager has drawn up a system which identifies staffs daily responsibility for supervising medication. All residents at present are unable to self administer their own medication. The Manager informed the Inspector that all staff who administer medication within the home have received training about this and which is also relevant to the home’s policy and procedures for medication. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be assured that their views will be listened to and acted upon appropriately. They can also be assured that they will be protected from abuse, neglect and self-harm. EVIDENCE: Standard 22 - All those service users interviewed by the Inspector confirmed that they feel their views are listened to and acted upon. They also all said that if they had a complaint they know the procedure to be followed and would do so if they needed to. Staff interviewed confirmed to the Inspector that the residents were all aware of the complaints process and that the whole staff group took any issues raised by residents seriously. The complaints record was reviewed by the Inspector, no complaints had been made since the last inspection visit. Standard 23 - The home has an adult protection policy (POVA) and the Manager informed the Inspector that the whole staff group had recently received POVA training. Evidence of staff training was seen in the files held in the main office. The Inspector saw the allegation of abuse record; no allegations had been made since the last inspection. The Manager confirmed this to the Inspector. The policies and procedures manual for the home includes a whistle blowing policy and a policy on dealing with violence and aggression. Understanding the Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 18 policies and procedures is a part of the staff induction process and staff are asked to sign to say that they have read and understood the policies and procedures. A review of staffing records held on staff files by the Inspector confirmed that all staff had signed such an agreement. The Manager informed the Inspector that training in this area is offered to staff. The home does look after some of the resident’s money and the Inspector reviewed the financial records for these transactions that were in order. All transactions are dated and signed for by both staff and residents to confirm satisfaction by all parties. The Inspector found no anomalies. It is recommended that an inventory for residents valuable belongings needs to be drawn up and maintained and kept up to date by key workers for all residents’ belongings that are kept in their bedrooms. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users do live in safe and comfortable surroundings and said that they are happy living in this environment. Service users may be assured that the home is clean and hygienic. EVIDENCE: Standard 24 – A tour of the premises together with the Manager covered all areas of the home including, with their permission, residents bedrooms. They told the Inspector that they are happy with their rooms. The general impression of the environment and décor of the home was found to be clean, hygienic and free from any unpleasant odours. However the floor in the first floor bathroom should be replaced, as it is cracked and liable to allow water to ingress and could lead to hygiene problems. Similarly the floor in the laundry area now needs replacement and should be made watertight. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 20 The coffee and tea making facilities in the smoking room which the residents use were not seen to be clean nor are they appropriately sited given the high level of smoking that takes place in this room. It is possible that foods could become contaminated and this is not satisfactory for residents who use these facilities. The Manager informed the Inspector that this problem had already been identified and both the Manager and the Proprietor assured the Inspector that it is planned to move these facilities in the very near future to another room thereby excluding the possible health dangers identified. Standard 30 – The home was seen to be clean and hygienic. Policies and procedures were seen to be in place and the laundry area is sufficiently far from the food preparation area to avoid any potential for cross infection. Appropriate hand washing facilities are provided for staff and residents who use the facilities. All staff have undertaken training in Infection Control, Health & Safety and Food Hygiene which assists in the maintenance of high standards in this home. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that they will be supported by competent and qualified staff. They can also be assured that they will be supported and protected by the home’s recruitment and supervision policy and procedures. EVIDENCE: Standard 32 - The Manager informed the Inspector that as a part of the induction process all staff are issued with job descriptions and are asked to read and discuss the homes policies and procedures. Evidence of this was seen by the Inspector on staff files and from discussions with staff interviewed. Staff have copies of the General Social Care Standards / Code of Conduct. Volunteers are not used within the home. The Manager told the Inspector that there is a training programme underway to ensure that all staff are NVQ qualified by the required date. 7 staff have or are completing their NVQ level 2 training and the remaining staff are identified for the next training course. Staff interviewed confirmed with the Inspector that they were just completing their NVQ training and evidence of NVQ training certificates were seen in the office records. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 22 Standard 34 - There is in place an appropriate recruitment policy. Staff files evidenced that suitable application forms are completed, that 2 references are obtained including one from the last employer. All staff files reviewed by the Inspector evidenced that proper CRB checks have been carried out for staff employed within this unit. Equally that all other documentary evidence required to be gathered for staff was seen to be held on the staff files reviewed. Staff interviewed confirmed that all have a contract of employment and that they understand their terms and conditions as well as their roles and responsibilities within the home. Standard 35 - The Manager informed the Inspector that there is an overall training and development plan and budget for the 3 units that make up the Laurel Group of Homes. Disaggregating the information specifically for Scott House was not possible. The Manager at Scott House is responsible for the training and development of the Laurel Group of Homes staff. The Manager informed the Inspector that a structured induction programme is offered to new staff and documentary evidence of this was seen by the Inspector on staff files and supported during the interview of staff. Recent in house training for staff has included: • Care planning • Boundary setting • Supervision • Health and safety • Fire safety • POVA • 1st Aid • Infection control • Medication • Food hygene Standard 36 - From discussions with the Manager and from interviews with 4 staff it is clear that at present staff receive ongoing supervision / support in the work they undertake and a supervision record is maintained that is signed by both parties. However there is no record made of key areas of discussion or of all the decisions and agreements made. It is required now that this is done as suggested and the whole process was discussed in full with the Manager and the Proprietor. 1:1 supervision should include the: • Translation of the homes philosophy and aims into working with individuals, • Structured monitoring of work with individual service users and the analysis of care plan outcomes, Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 23 • • • Support and professional guidance, and the Identification of training and development needs, Annual appraisals. The Manager has informed the Inspector that this form of supervision is being planned now for implementation in the near future. This is welcomed as this structured supervision will greatly assist the unit in meeting some of the needs identified in this inspection report. The Inspector is advised that all staff will receive supervision at least once every 2 months. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users benefit from a well run home and when completed the quality assurance process will ensure that service users can be confident that their views and those of other relevant people underpin the development and review of the home. The health and safety of service users and staff are protected by the policies and working practices in the home. EVIDENCE: Standard 37 - The Manager at Scott House has had considerable experience in a senior management capacity and has completed NVQ level 4 training. During the course of this inspection the registered manager’s competence, enthusiasm and commitment to improve the services provided for residents at Scott House impressed the Inspector. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 25 Standard 39 - The Inspector spoke to the Manager and Proprietor about the development of the quality assurance system referred to in the last inspection report. The current QA system gathers information from residents about different aspects of the unit for instance with regards to food, the environment, and to do with staff. Whilst this information is useful and is being used by the unit to develop its services now, it requires further expansion to seek feedback from the families and carers of residents, from referring professionals and other key stakeholders who all have a valuable contribution to make to this process and whose views will assist in the further development of effective service provision at Scott House. Survey questions need to be developed in order to provide feedback, which covers aspects of the service such as key working, care, plans, rehabilitation programmes and activities. This remains a requirement. The Manager informed the Inspector that the survey of staff as a part of the quality assurance process and which was started with the staff at Russell Hill is to be extended this month to the staff at Scott House. This is a good contribution to the whole process and will provide excellent feedback for improving services within the Laurel House group. Standard 42 - Information was seen in the office to do with relevant Health and Safety legislation. Policies and procedures were also seen for Health and Safety, risk assessment, moving and handling and fire. The Manager informed the Inspector that all staff receive training in moving and handling, fire safety, first aid, food hygiene, and infection control. This was supported by staff interviewed that confirmed that they had received training in these areas. Up to date certificates were seen by the Inspector for: Boiler / gas Fire alarms Fire extinguishers. An accident record book is being used at the home to record any accidents to staff although nothing had been recorded since the last inspection. Records were seen by the Inspector for: Weekly fire alarm tests Fire extinguisher checks Emergency lighting tests. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. With regards to COSHH materials, all are safely stored in a locked cupboard and safety notices displayed. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 26 Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes. 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. 2. Standard YA36 YA39 Regulation 19 24 Requirement Supervision should be recorded. The previously set timescale has not been fully met. The quality assurance system must be extended as agreed. The previously set timescale for this requirement has not been fully met. That care plans include more detailed objectives, which could expand the range, and scope of service user’s life’s to include health and social care objectives. Food records should record what each resident has actually consumed reflect this in the context of his or her healthcare needs. The floor in the first floor bathroom and in the laundry should be replaced. Timescale for action 01/02/07 01/02/07 3. YA11 YA19 14 01/02/07 4. YA17 16 01/12/06 5. YA24 23 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 29 No. 1. 2. Refer to Standard YA2 YA5 Good Practice Recommendations That the Manager should always request full documentation from referring agencies at the time of their requesting a new placement. That the Manager ensure that each resident at Scott House does have a written contract signed and dated by each party which covers all the requirements set out in Standard 5.2 of the National Minimum Standards for adults (18-65). An inventory for residents valuable belongings needs to be drawn up and maintained and kept up to date by key workers for all residents’ belongings that are kept in their bedrooms. 3. YA23 Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 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 Scott House DS0000025834.V311835.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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