Inspection on 14/11/06 for Scotts Project Trust

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Scotts Project Trust 11/11/08

Scotts Project Trust 25/09/07

Scotts Project Trust 13/02/06

Scotts Project Trust 20/09/05

Scotts Project Trust 27/10/04

Scotts Project Trust 13/05/04

Scotts Project Trust 30/12/03

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

CARE HOME ADULTS 18-65 Scotts Project Trust 1-3 St Peters Row Delarue Close Shipbourne Road Tonbridge Kent TN11 9NN Lead Inspector Maria Tucker Key Unannounced Inspection 14th November 2006 08:35 Scotts Project Trust DS0000024009.V316489.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 Scotts Project Trust DS0000024009.V316489.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. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scotts Project Trust Address 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) 1-3 St Peters Row Delarue Close Shipbourne Road Tonbridge Kent TN11 9NN 01732 771593 01732 378945 Scotts Project Trust Miss Alise Dawn Garrett Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. People with a learning disability may also have a physical disability Date of last inspection 13th February 2006 Brief Description of the Service: The Scotts Project Trust is a detached terrace of three interconnecting houses with accommodation on two floors. There are fourteen single bedrooms all with a television point and three of these bedrooms are on the ground floor as there is no lift to enable disabled access to the first floor. None of the rooms have en-suite facilities or call points installed. There is one bathroom to every two bedrooms. There are no facilities for guests to stay overnight. There is a large multi-purpose hall and a converted barn on the site for the use of the service users and day users. The project is approximately two miles from the town of Tonbridge in a quiet cul-de-sac set back from the main road. There are local shops, including a post office, chemist and library, and also a public house and church just half a mile away. The fees range from £762.99 to £1017.77 per week. Extra charges for Chiropody, toiletries, transport, haircuts, magazines, holidays and Hydrotherapy Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection lasting from 8.25 am to 4 pm. Time was spent talking with the manager, deputy manager and care staff. Service users were spoken with individually and collectively. A partial tour of the building was undertaken. The pre inspection questionnaire has been received, as has comment / feedback cards from service users, health and social care professionals, visitors and relatives. Overall the feedback was very positive comments received included: • We are more than happy with the care given. We feel fortunate to have our (service user) resident at scotts project • Scotts provide an exemplary service. • Staff are nice and care for me well Throughout the inspection, there was an inclusive atmosphere, with the service users feeling comfortable and relaxed. What the service does well: The service excels in the way in which service users are treated and respected as independent adults but with the support of a small family type unit and regular staff team. Each person is recognised as an individual with their own needs and supported to exercise rights and choices. Health care and clients rights are fully promoted in the home Service users join in with an extensive range of activities; including regular holidays and weekends away. Without exception all service users spoken with were excited about the yearly pantomime which was a big topic of conversation as well as positive comments made by service users in the have your say comment cards received. If a service user chooses, home visits are encouraged and contact can be kept by phone or in person with friends and family. Service users are able to take part in the daily routines of the home, to socialise or be more private. Each client has a good-sized bedroom, which they make his or her own. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The service users would benefit from having some of the carpets replaced where they have become stained or ripped. Where service users have wheelchairs it may be worth thinking about having more suitable flooring especially in the entrance. The home would benefit from having a assessment made by the infection control nurse who would be able to offer advice on the current use of red bags for laundry; the storage of cleaning facilities; the laundry room and the possibility of cross infection due to limited working areas and a lack of shelving or storage; with the location and advice on having a sluice facility installed. Service users would be better supported in the morning with a more suitable complement of staff able to meet their needs. On the day of the inspection staffing numbers until 9.30am were four care staff. This led to service users having an ad hoc service and staff being rushed and too busy to fully oversee service users’ needs or support them appropriately. This was discussed and it is noted that this was due to staff training and sickness and was not the norm. The home must conduct risk assessments prior to having any work carried out to the home or the grounds. On the day of the inspection a patio area was being built with trailing wires; cement mixer in use and holes in the ground. Service users were noted to be walking past these hazards unescorted. Service users would benefit from having a rota of all of the staff that were on duty and were due to come in which would enable them to plan more effectively what they may like to do and with whom and provide reassurance. The office area is open and used as a main entrance, there are documents on the wall and around the office, which for data protection purposes and dignity should have not been in view. It was discussed during the inspection that there might be a possibility of re locating the office so that this area can be used as a greeting reception area. It is currently used as a busy thoroughfare where telephone conversations and administration working can be seen and heard and visitors and members of the public and invited in. Service users’ records need to be kept more secure and out of view to visitors. The home has interlocking doors that provide an upstairs and downstairs entrance to each of the units from one to the other. It was noted that during the inspection staff continually used these as a means to get into each unit. Consideration should be made as to the use of these especially in the upstairs areas where service users’ private accommodation and bathrooms are located as persons can walk through at any time which compromises the dignity and Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 7 respect of the service users and gives them little control over their own home in whom to let visit or not. The care plans are working documents that contain a vast amount of information. They would benefit from having them streamlined so that information is not repeated or old information is stored. Risk assessments on activities need to be more robust for service users. The home would benefit from having extra management arrangements as currently the manager is overseeing other areas of the running of the organisation and developments to the detriment of the home and service users. The home would benefit from having a review and changes made to the medication procedure including the PRN (when required) and the storage of the documentation. 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. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 8 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 Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to visit the home and make an informed choice of moving into the home. EVIDENCE: No new service users have been admitted since the last inspection. The home has a good record of introducing prospective service users to the home as discussed and identified in previous inspections. A comment made by a service user in the have your say comment card evidenced that prospective service users are invited to visit the home prior to making the decision to move in as stated ‘I like the view here and I did look round with (staff member) and my family’. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ information is not kept secure or in a format that is easily understood by staff or service users. EVIDENCE: Service users have a comprehensive care plan detailing all aspects of holistic care. The care plans would benefit from being streamlined so that the information for daily support is easier to find and staff are able to record with more accuracy that care plans have been followed. Care plans need to be more user friendly. The risk assessments need to be more versatile and user friendly, describing potential risks and actions taken to minimise risk. Currently there are many risk assessments that are repetitive and not being used as a way of enabling service users or ensuring that risks are fully assessed with all concerned. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 11 A comment received in a comment card from a social care professional evidenced that the home are proactive in working with the outside agencies as stated “Communication between myself and the home is good”. Comments received by relatives in the comment card “We are more than happy with the care given. We feel fortunate to have our (service user) resident at scotts project”. Service users were exercising choice and opportunity throughout the inspection in aspects of their daily life and in the running of the home. Service users manage their own finances and those that require support receive this. A comment made by a relative in the comment card stated that the “Scotts provide an exemplary service. We feel however that the staff are forced by legislation to sometimes have to ask the residents to make decisions on matters that are beyond them”. The pre inspection questionnaire states that some of the policies and procedures are in formats that are understood by the service users. The manager described how difficult she found it to translate the outcomes of the last quality assurance feedback to the service users. It was discussed that this does not have to be complicated, as some service users may not fully comprehend all that has been stated. Service users hold meetings as a way of being included and influence the running of the home and the service provided. Service users files were noted not to have been locked away or secure in the individual units. The office had an open view from outside and was used as a main entrance for visitors. The walls had items relating to service users and staff. Visitors were noted to be in the houses and invited into the office. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run for the benefit of the service users where individual choice and opportunities are maximised. EVIDENCE: There is a good range of food available that is chosen with staff by service users. During the inspection service users were given support and helping themselves to what they wanted for breakfast. Each service user had what they wanted and staff were familiar with preferences. It was noted that a service users who made themselves a marmalade sandwich had put an excessive amount of marmalade in between bread that they then folded over. This was not supervised or monitored by staff. A comment made by a service user in the have your say comment card when asked if they liked the meals stated Do you like the meals “everything but not quiche or fizzy water” and Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 13 that the “Size and portion at meal times are getting bigger would like smaller”. Service users spoke of how they enjoyed shopping for food and took it in turns to do so as evidenced further in a comment received from a service user in the have your say card “I enjoy helping to choose the meals for the week and going to do the food shopping” another service user stated I like the menu here and do house shopping with staff”. A service user commented in the have your say cards that “I need more support for my independence and doing well and bus training”. Service users were seen to be given assistance with tasks and getting ready although due to the limited number of staff this was compromised. Service users were positive about their independence and proud at the opportunities and things that they were learning to do. A communication aid was seen to be in use. Service users are supported to have their spiritual needs met. A service users comment received in the have your say comment card that “When I cry or get upset the staff don’t cheer me up all the time”. This was discussed with the manger and it was decided that this was due to the immaturity due to the age and experience of the service users and leaving home having an impact. A comment made by a service user in relation to activities they enjoyed they expressed this to be, Christmas dinner with the house every year, concerts and theatre another commented that Staff always make time to take me out get me to work on time stating that “I am happy at Scotts”. Service users have a vast range of activities and daily educational and work experiences that they are supported with. Service users spoke of how they had enjoyed a recent holiday and were looking forward to planned future events. Friends and family are made welcome and service users are supported to maintain family links as evidenced through a discussion of a home visit by a service user. Service users were seen to be moving about the house and grounds freely. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are empowered to have control over their lives. Staff provide the dignity and respect that service users need to facilitate this. The medication practices need to be improved to reduce the risk of incidents occurring. EVIDENCE: Staff support service users with personal development and hygiene. It is acknowledged that the lack of staff to offer support during the inspection was unusual. Service users spoke of how they chose when to have a bath and could go to bed at a time of their choosing. All service users had personal effects including clothing that were to their taste and reflected their personality. The pre inspection questionnaire lists a range of health and welfare in put including general practitioners and chiropodists. The individual care plans contained assessments by health and social care professionals. One service user detailed how they were going home to visit their local dentist. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 15 A service user made the comment in a have your say card that “We talked about how important it is to tell someone if we are not happy especially even if someone you know well makes you unhappy”. One service user spoke of how they self medicate. Others were seen to be given their medication by staff. The medication recording charts (Mar) were in individual files. It was discussed that this procedure should be reviewed as staff assume this responsibility with the expressed permission of the service user. It was noted that some errors had been made with medication not being given. Although this was managed and advice sought it is recommended that the process of medication storage; administering and overseeing should be reviewed and improved upon so that it is more robust with incidents being monitored and action taken to prevent further incidents. The PRN when required medication was not detailed enough in that it was not clear what or how many should be taken. It was discussed that a more robust system including information of preferences in relation to medication should be made. That the prescribing should not just state when required. It is acknowledged that some of these problems are due to circumstances not within the control of the home and that the home was in the process of addressing this. The training for staff tended to be via staff training each other. There had been some staff trained externally although there was no evidence that this had been updated. Staff competency following in house training was via supervision and questioning. It was discussed that formal training should take place that these should be based upon the skills for care and should be accredited. A copy of the guidelines for administration of medication and controlled medication in care homes was left at the home. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that any complaints they have will be listened to and these would be fully investigated. That there are systems in place, which will ensure their protection. EVIDENCE: A comment received by a service user in the have your say comment card when asked if staff listen stated Staff listen “yes but not always” and on complaints stated “some peps say that I am not supposed to”. Another service user stated when asked if staff listen “They do listen to us and I understand them all the time” and on complaints stated “yes I do I have my right to do one”. The pre inspection questionnaire stated that 23 complaints have been made (all from service users about other service users) that all of these have been managed within 28 days and all substantiated. The record of complaints were viewed and discussed. Service users felt able to complain about behaviours that they considered they did not like many of these were taken as official complaints and investigated by the manager. It was discussed that some may have been managed at the time by staff as they had dealt with situations such as knocking on another service users door, Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 17 which then could be addressed overall with the service users through some more work around group living. Staff receive training on adult protection. There have been no adult protection alerts raised. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Service users live in a comfortable environment that is well equipped to meet their needs. They would benefit from a review as to the use of some areas such as the office, laundry and the practice of using the interlocking doors to gain access into the other units. EVIDENCE: Overall the home was found to be very well maintained and well decorated with high quality furnishings and fittings. There are some radiators that have not been covered; these are in communal areas and the manager has expressed that the system has 2 thermostat controls so that these can be safeguarded. Some of the carpeted areas were stained and in need of being replaced. It was discussed that where service users use wheel chairs they may be best replaced with a different type of flooring that is easier to manoeuvre around and could be kept clean. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 19 All of the service users rooms inspected were very personalised and suited to taste. Service users were very proud of their rooms and their possessions and one service user with support was busy cleaning their room. The bathrooms and toilets were clean and free of any offensive odours. It was discussed that the home has thought about having a sluice fitted and the inspector was telephoned to discuss this. It is recommended that advice regarding this would be best sought from the infection control nurse who has specialist knowledge in this area. During the inspection a patio was being laid to the rear of the building. There was trailing electricity wires and a cement mixer at the front of the building. There were no warning signs in place nor had a risk assessment taken place. The home has interlocking doors that provide an upstairs and downstairs entrance to each of the units from one to the other. It was noted that during the inspection staff continually used these as a means to get into each unit. Consideration should be made as to the use of these especially in the upstairs areas where service users private accommodation and bathrooms are located as persons can walk through at any time which compromises the dignity and respect of the service users and gives them little control over their own home in whom to let visit or not. It was discussed during the inspection that the office was used as a thoroughfare with people coming and going. That this area would be best suited to a reception area so that people can be greeted and not enter the premises where there may be paperwork or telephone conversations going on. A service user was seen to knock on the door from their unit’s entrance and waited until they were invited in. There are assisted baths and equipment in place to support service users who have physical needs this includes one kitchen area that had work surfaces that were suitable for wheelchair users to access. The garden areas were well designed and well kept. The patio area out of the back was in the process of being extended for greater access. The laundry rooms were small and compact with little room made for working areas or storage. The cupboards were not locked and contained cleaning materials. There are red bags in use for foul laundry although this practice should be reviewed as to keeping the bag open in a service user’s room and the possibility of cross contamination from laundry that was piled on the floor together. It was discussed that this could be addressed through the advice and guidance sought from an infection control nurse, as could the possibility of having a sluice room fitted. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported through a dedicated staff team who have a good understanding and insight into the needs of the service users. This is reinforced through good training opportunities. Service users’ care has been compromised due to a low staff level. EVIDENCE: The staff at the Scotts project have clearly defined roles and responsibilities. The organisation structure consists of a manager, deputy manager, team leaders and care support staff. There is other staff for administration, cleaning and maintenance. Job descriptions are held on files. The staffing rota indicates that 6 staff are on duty am and pm with 5 am and pm on duty at the weekends. On the day of the inspection there were 4 care staff on duty until 9.30 am when the manager and deputy manager came on duty. It was stated that this was due to staff training day and sickness. As Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 21 discussed throughout the inspection report the lack of staffing impacted upon the support offered to service users in the consistency of care being provided. Throughout the inspection staff were undertaking their roles in supporting service users with their daily routines. Exceptional practice was noted in the interaction between staff and service users in the manner in which the support was delivered and the rapport and mutual respect between service users and staff. The pre inspection questionnaire lists 5 staff as having the NVQ level 3; plus 1 bank staff; 3 staff as having NVQ level 2 with 40 of staff. There have been 3 staff leave who have either attained the qualification or working towards it. Two staff are due to commence work who hold the NVQ level 3. The home has a staff-training matrix that identifies mandatory training and indicates when training is due to be renewed. As identified earlier external training for medication is required. There is a good broad range of training available that covers specialist aspects for this service user group. Supervision for staff is conducted regularly with records held. In the interest of confidentiality these were not inspected. Staff confirmed they received regular supervision. From document reading and discussions with the manger it was evidenced that the home have good robust procedures in place for the recruitment and induction of new staff. A buddy system is in operation where a new staff works alongside a designated staff to support them through their induction. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a service that is run for their benefit. There are systems in place to ensure their safety and welfare, however these need to be monitored more closely through a more robust organisation structure and management system. EVIDENCE: The manager meets all the requirements of a registered manager and is competent and experienced in managing the Scotts Project. It was discussed that due to other ventures being set up in the organisation this has led to a difficulty in fulfilling the expectations and functions of managing the home on a daily basis. The manager explained that this is recognised and there have Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 23 been discussions held within the organisation of recruiting a full time manager so that the current manager can take a step back from this role. The layout of the home does not lend itself to having an office that is designed to enable staff to sit and work interrupted. There is a second office in another building on site where the manager is situated. This does not allow the manager to be instantly on hand for staff or service users. The organisation structure provides a clear direction of leadership accountability and authority. It is recognised that the structure needs to be reviewed given the other commitments of the organisation. There were some aspects of the running of the home such as the practice of using a red bag for laundry and the low staffing level on the day of the inspection that the manager was not made aware of. During the inspection process all staff were open and transparent with any advice or guidance given being welcomed. Staff meetings and service users meetings are held regularly, minutes seen evidenced that this is an inclusive process where things are openly discussed and provides a format for the quality of the service to be explored. There has not yet this year been a formal quality assurance audit to seek the views of the service users and stakeholders. The manager explained that following the last questionnaire she had some difficulties in assimilating this information so that it could be fed back to service users in a meaningful way. This is something the manager is working on. The home has not as yet developed an annual development plan. The home has a vast range of policies and procedures some of which are in formats suitable for the service uses. The pre inspection questionnaire lists these with review dates. The pre inspection questionnaire lists the maintenance and associated records. These were spot checked during the inspection. Staff were seen to be recording information such as temperature checks and dating food. Scotts Project Trust DS0000024009.V316489.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X 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 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 1 1 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 2 2 3 X 2 X Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 25 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 YA10 Regulation 17 Requirement Timescale for action 26/12/06 2 YA20 13 (2) 3 YA24 13 4(c) 4 YA33 18 (1) The registered person shall ensure that the records and details of service users are kept secure and in accordance with Data protection. The registered person shall make 26/12/06 arrangement for the recording, handling, safekeeping, safe administration and disposal of medicines in the care home. In that a more robust policy and procedure for medication be put in place as identified in the main body of the text. The registered person shall 26/12/06 ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. In that any building work or maintenance work is risk assessed and action taken to minimise any potential risk. The registered person shall 26/12/06 having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and DS0000024009.V316489.R01.S.doc Version 5.2 Scotts Project Trust Page 26 5 YA33 17(2) 6 YA39 24(1)(5) experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The home shall keep and 26/12/06 maintain a copy of the duty roster of persons working at the care home, and a record of whether the roster was actually worked. In that all persons shall be included on the rota with their full names and designation. Schedule 4 7 The registered person shall 01/04/07 establish and maintain a system for evaluating the quality of the services provided at the care home. This system shall provide for consultation with service users and their representatives. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is strongly recommended that the care planning system be reviewed and made simpler to enable service users to be fully included in this process. To slim down the information contained and repetition so that they are easier for all to follow. It is recommended that the risk assessment format be reviewed and changed as identified in the body of the text. It is very strongly recommended that the areas of the carpet where they are stained and one area that is ripped be replaced. That consideration be made as to the replacing of flooring be suitable for service users in wheel chairs. It is very strongly recommended that the office be reviewed as to its location given that this is a through fare and the main entrance. DS0000024009.V316489.R01.S.doc Version 5.2 Page 27 2 3 YA9 YA24 4 YA24 Scotts Project Trust 5 YA24 6 7 YA30 YA38 It is very strongly recommended that a review be made as to the upstairs doors that are interlocking into other units. And the use of the downstairs interlocking doors instead of going out of the unit’s entrance or through the staff room. It is very strongly recommended that the advice and guidance be sought from the infection control nurse in relation to issues raised in the main body of the report. It is strongly recommended that a review be made as to the management and organisation structure of the home to ensure that the good record of management is facilitated. Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Scotts Project Trust DS0000024009.V316489.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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