Inspection on 12/09/05 for Bevan House

This inspection was carried out on 12th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bevan House 08/01/08

Bevan House 14/03/07

Bevan House 24/04/06

Bevan House 15/11/04

Bevan House 28/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Unicorn House (104) Unicorn House 104 Coldharbour Road Croydon, Surrey CR0 4DW Lead Inspector James OHara Announced 12 September 2005 09:30 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 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 Stationary 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. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Unicorn House (104) Address Unicorn House, 104 Coldharbour Road, Croydon, Surrey, CR0 4DW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8726 7811 020 8686 0135 Mr Maharajah Madhewoo Mr Dhaneshwur Noruthun Care Home 3 Category(ies) of LD Learning Disability (3) registration, with number of places Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22 July 2005 Brief Description of the Service: 104 Coldharbour Road is a terraced house registered as a care home to provide accommodation and care to three adults with learning disabilities, between the ages of 18 and 65 years. At present there are two service users living in the home. The staffing level is set at one staff member per shift only. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected under the National Minimum Standards. This announced inspection started at 9.30am and finished at 1.30pm on a Monday morning/afternoon. Asha Ramprasad the deputy manager from another of the Unicorn Projects homes supported the registered manager Mr. Noruthun. Methods of inspection included previous inspection experience of the home, a tour of the premises observation of contact between staff and service users, discussion with one service user and the Mr. Noruthun and Asha. Previous requirements and recommendations were discussed. Records examined included medication records, service user and staff support guidelines, service users finances, Person Centred Plans and reviews, complaints, administration and recording systems, regulation 26 visits, Criminal Records Bureau Checks, recruitment records, staff supervision records, training records and induction training. What the service does well: What has improved since the last inspection? What they could do better: There were twelve requirements and two recommendations set at the last inspection as a result of this inspection there are now eleven requirements and five recommendations. The last inspection report stated that “given that a large number of requirements from the last inspection have not fully been addressed this indicates that not enough emphasis is placed upon improving the level of Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 6 quality service to the service users at the home” although a number of requirements have been met there are still a number of requirements yet to be fully addressed. The Commission for Social Care Inspection has concerns that the number of new requirements and the failure to address existing requirements is as a result of the registered manager working full time at another registered service. It is of concern that the registered provider Mr. Madhewoo has still not resolved this dual working arrangement in respect of his manager, particularly as an application has been received from Mr. Madhewoo to increase the registered numbers of service users from 3 to 6. Further development of this home will be dependent on the delivery of good quality services to the current service users. As well as the above concern the following areas were also identified. The home should ensure that appropriate guidelines for staff to support service users particularly in respect of challenging behaviours and physical aggression are in place thus enabling them to support service users in a confident manner. The homes Lone Working Policy should be reviewed. The home should introduce an appropriate staff induction procedure. The home should ensure that all documentary evidence required for the protection of service users is obtained prior to staff starting employment at the home. The home must develop an appropriate procedure for reporting Incidents and Accidents and that all staff should be made aware of the procedure. The home should ensure that service users finances are appropriately managed and recorded. The inspector would like to thank the service users, the staff and management of the home and all of those who provided feedback for their support in the inspection process. Please contact the provider for advice of actions taken in response to this inspection. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. The registered manager has made limited progress in ensuring that all staff receive appropriate approved guidance so that they can meet the assessed needs of the service users. EVIDENCE: The requirement set at the last inspection that the home manager ensures that the service user with epilepsy attends the epilepsy clinic and the home manager seeks the advice of professionals when completing staff guidelines for the support of this service user should he have an epileptic seizure has yet to be fully adressed. The registered manager Mr Noruthun stated that he has contacted the epilepsy clinic at Mayday Hospital and is awaiting an appointment so that the service user can have his epilepsy assessed. There are now guidelines for staff to follow in the event of the service user having an epileptic siezure however these have been drawn up by mr Noruthan and need to agreed by the Epilepsy Clinic. Mr. Noruthun stated that these guidelines would be reviewed at the epilepsy clinic when the service user attends his appointment. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 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 standard(s) 6 and 9. More emphasis has been placed on providing support guidelines for staff to follow in order to meet the service users assessed needs. EVIDENCE: As stated at the recent unannounced inspection that took place on the 22nd July 2005 Service user plans, care plans and risk assessments are reviewed on a regular basis. One service user has a wish to drive a car and sometimes gets anxious about this. Care plans indicate that when the service user talks about wanting to drive that he is told that he can’t drive because of he is not well. It is recommended that the registered manager seek opportunities for the service user to experience driving in a controlled risk assessed environment i.e. go carting or simulators. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 11 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 standard(s) 13. Adequate provision is made so that service users attend appropriate social activities and day centres which allows them an opportunity to be involved in the wider community. EVIDENCE: As recommended at the last inspection the fact that service users do not wish to attend other social and educational activities outside those offered by the Unicorn Project has been discussed by the service user and registered manager and recorded in their person centred plans. It is recommended that is discussed at the next Person Centred Plan review. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 12 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 standard(s) 19, 20 and 21. The absence of appropriate guidelines for staff to assist them to support service users particularly in respect of challenging behaviours and physical aggression reduces the ability of staff to fully meet the services user’s physical and emotional needs. Medicine administration records were generally recorded accurately, however regular medication reviews with the service users General Practitioner are required to fully protect their health. EVIDENCE: As previously stated in this report Mr Noruthun has contacted the epilepsy clinic at Mayday Hospital and is awaiting an appointment so that the service user can have his epilepsy assessed. There are now guidelines for staff to follow in the event of the service user having an epileptic siezure. During the last inspection it was identified that a service users PRN medication had been stopped. At that time Mr Noruthun said that the PRN had been stopped by the service users General Practitioner however there was no evidence in the service users medication records to suggest this was the case. The requirement set at the last inspection that the registered manager ensures that the service user visits his General Practitioner and has a review of his Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 13 current medication and ask the General Practitioner to refer to his PRN medication being discontinued has yet to be fully addressed. Mr. Noruthun stated that he has contacted the service users General Practitioner and Consultant Psychiatrist to clarify the situation regarding the service users PRN medication being discontinued. It was noted at the last inspection that a service user had been verbally and physically aggressive to a female member of staff, who has since left employment at the home, whilst she worked alone on shift. A requirement was set that the home manager ensure that there are guidelines for staff to follow in the event of the service user presenting challenging behaviours. Guidelines have been set in place however these fail to address the event of physical aggression from the service user towards staff. The registered manager must ensure that there are guidelines for staff to follow in the event of the service user presenting challenging behaviours including physical aggression. The home has a Lone Working Policy that indicates that staff should carry one of the homes two portable phones and if need be contact the on call person identified on the homes staffing rota. The home does not have portable phones and the homes staffing rota does not indicate who is on call. The registered manager must review and amend the homes Lone Working Policy and the homes rota should indicate who is on call. As previously required the service users views about terminal care and any religious or cultural customs they would like to be observed after their death is now recorded in their service user files. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 14 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 standard(s) 22 and 23. The home has an appropriate complaints procedure. Staff has recently attended vulnerable adult protection and abuse training thus ensuring that service users are so far as reasonable practicable protected from abuse, neglect and/or harm. EVIDENCE: The home has a book for recording complaints Mr. Noruthun stated that there have been no complaints made to the home by the service users, staff or by any other persons in the last twelve months. Staff records indicate that all staff recently attended Protection of Vulnerable Adults training. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 15 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 standard(s) 24. Significant improvements to the physical environment of the home have been made to ensure the service users live in a more homely and comfortable environment. EVIDENCE: The flooring in the bathroom has been replaced and the bathroom no longer smells of damp, the tiling in the shower unit has been replaced as required at the last inspection. The hot tap in the shower room now works however because of the type of tap and the direction of the flow of water there is a high risk of soaking the user and the shower room floor, a conventional tap should be fitted. The wallpaper in one of the service users bedrooms is worn and ripped in areas. It is recommended that the service users bedroom be redecorated. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36. The home does not have an appropriate staff induction procedure, without improvement this could affect the staffs ability to consistently meet all a service users needs. The homes recruitment procedure does not ensure that documentary evidence required for the protection of service users is obtained prior to staff starting employment at the home. Thus the home is failing to ensure that so far as reasonably practicable that the service users are not placed at risk of harm or abuse from individuals who are ‘unfit’ to work with vulnerable adults. EVIDENCE: Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 17 The registered provider for the Unicorn Projects Mr. Madhewoo has historically employed students from Mauritius to staff his care homes on a part time basis. Given the size of the home and the staffing levels there is a high turnover of staff. At the inspection on the 15th November 2004 Mr Noruthun said that it was the registered provider’s Mr. Madhewoo’s plan to recruit a more culturally diverse staff team that would reflect the cultural needs of the service users living at the home. At the last inspection Mr Noruthun said that the three recent staff appointments reflect more the culture of the service users. Two of these staff remain and another new member of staff, a student from Mauritius has started work since the last inspection. At the last inspection two new members of staff had recently started to work at the home. Staffing records indicated that both staff had only one reference. On closer examination during this inspection it was noted that these references are a Statement of Work Experience from their previous employment as nurses at a hospital in China and not a reference requested specifically for Coldharbour Road or the role of a support worker. The registered manager must ensure that both members of staff with a Statement of Work Experience from their employment in China obtain two written references preferably from those indicated as referees on their employment applications. The new member of staff started work in the home in August 2005. He has a completed Criminal Records Bureau Check however references have been taken from two people who live at the same address as him and both referees indicate that there are family friends. The registered manager must obtain two written references for the new member of staff from his previous employers or from the college where he is a student. The new member of staff started work in the home in August 2005. On the day he started a Wednesday he worked from 8.30am till 11am and completed the whole of the homes induction with the registered manager. The new member of staff then worked alone with service users on a late sleepover early shift on the following Sunday and Monday. The new member of staff has no previous experience of working with people with learning disabilities was not shadowed by experienced member of staff on shift at any time prior to starting work at the home. The registered manager must ensure that a proper induction package is drawn up for all new staff recruited to the home. This should include one to one support and shadowing before staff is asked to work alone in the home. All staff now has a contract of employment contained in their files as required at the last inspection. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 18 Criminal Records Bureau Checks were seen for all members of staff as required at the last inspection. There was evidence that all members of staff have had regular supervision as required at the last inspection. None of the staff are currently completing an Appraisal. Mr. Noruthun said that this is due to the fact that they are new members of staff. One member of staff however has worked at the home for over two years. It is recommended that the registered manager ensure that the member of staff employed at the home for over two years completes an appraisal. This will offer guidance to the registered manager when appraising new members of staff when the time comes. Staff training records indicated that all staff has attended training on Understanding Epilepsy, Food Hygiene, Health and Safety and Fire Awareness, Basic First Aid and Protection of Vulnerable Adults. The deputy manager stated that staff have completed training and are awaiting certificates for Mental Health, Aspergers and Non Violent Crisis Intervention. Staff training records indicated that all staff has attended training on Understanding Epilepsy, Food Hygiene, Health and Safety and Fire Awareness, Basic First Aid and Protection of Vulnerable Adults. The deputy manager stated that staff have completed training and are awaiting certificates for Mental Health, Aspergers and Non Violent Crisis Intervention. The deputy manager also stated that Medication and Moving and Handling training is currently being arranged. The deputy manager also stated that Medication and Moving and Handling training is currently being arranged. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39 and 41. Whilst Mr Noruthun still continues to work full time in another registered setting, service users will continue to receive a lower quality of service. The benefits that accrue for staff from consistency of leadership and regular management oversight are not yet established and this is to the detriment of the service users in the home. EVIDENCE: As indicated at the last inspection the Commission for Social Care Inspection has concerns that Mr. Noruthun works full time at another care establishment while at the same time is the registered manager at Coldharbour Road. As his employers organize the rota in his substantive full time post it results in Mr. Noruthun working at Coldharbour Road in the remaining free time. This means that the availability of Mr. Noruthun to undertake the serious responsibilities associated with being a registered manager are dependent on the needs of his full time employer and not the needs of the service users or staff at Coldharbour Road. Mr. Noruthun stated that he still works on a full time basis at another care establishment. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 20 The last inspection report stated that “given that a large number of requirements from the last inspection have not fully been addressed this indicates that not enough emphasis is placed upon improving the level of quality service to the service users at the home” although a number of previous requirements have been addressed there are still a high number of requirements. It was stated in the last inspection report that the Unicorn Project had started to undertake monthly Regulation 26 visits at this home. These visits by a person not in day-to-day management of the home and are in order that the proprietor Mr Madhewoo is informed on a monthly basis of the positive and negative aspects of the home. A large number of issues were identified during this regulatory visit. Which highlighted the concerns already raised about the day-to-day management oversight of the home. A number of issues have now been addressed by the home. However no further Regulation 26 visits took place at the home in July or August. Mr. Noruthun stated that a Regulation 26 visit took place the day previous to this inspection and he is awaiting a report. The registered manager must ensure that Regulation 26 visits are carried out at the home on a regular monthly basis and that copies of these reports are sent to the Commission For Social Care Inspection. It is recommended that timescales for action were included to the Regulation 26 visit format. The home has a procedure for reporting Incidents and Accidents to appropriate people however the Mr. Noruthun produced three different types of Incident and Accident reporting form. Mr. Noruthun was uncertain as to which form is to be used by staff in the home. The registered manager must ensure that there is an appropriate procedure for reporting Incidents and Accidents and that all staff is aware of the procedure. The registered provider Mr. Madhewoo is the appointee for both service users. Regular monthly bank statements where seen for both service users. It was noted that the appointee drew out a large amount of money in May 2005. When asked what the money was withdrawn for Mr. Noruthun said that he did not know, he had contacted the Unicorn project to find out at the time but was not told why the money was withdrawn. The registered manager must contact the service users appointee to enquire what this sum of money was withdrawn for and request a receipt for the service users financial records. One service user recently purchased a new computer. Mr. Noruthun says that this service user has his own bank debit card and withdraws his own monies but he is sure that the service user keeps his receipts. The service user in question was out on the day of the inspection. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x 2 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 x x x x Standard No 31 32 33 34 35 36 Score x 2 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Unicorn House (104) Score x 2 2 3 Standard No 37 38 39 40 41 42 43 Score 2 3 2 x 2 x x G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 22 yes. 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 3. Regulation 13 (1) b Requirement The home manager must ensure that the service user with epilepsy attends the epilepsy clinic and the home manager seeks the advice of professionals when completing staff guidelines for the support of this service user should he have an epileptic seizure. The requirement that the home manager must ensure that the service user visits his General Practitioner and has a review of his current medication and ask the General Practitioner to refer to his PRN medication being discontinued has yet to be fully addressed. The registered manager must ensure that there are guidelines for staff to follow in the event of the service user presenting challenging behaviours including physical aggression. The registered manager must review and amend the homes Lone Working Policy and the homes rota must indicate who is on call. The hot tap in the shower room now works however because of Timescale for action 31/12/05 2. 20. 13 (1) 31/12/05 3. 19. 18 (1) c 31/12/05 4. 19. 12 (1) 31/12/05 5. 24. 23 (2) c 31/12/05 Page 23 Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 6. 34. 19 (1) b 7. 34. 19 (1) b 8. 32. 18 (1) c the type of tap and the direction of the flow of water there is a high risk of soaking the user and the shower room floor, a conventional tap should be fitted. The registered manager must ensure that both members of staff with a Statement of Work Experience from their employment in China obtain two written references preferably from those indicated as referees on their employment applications. The registered manager must obtain two written references for the new member of staff from his previous employers or from the college where he is a student. The registered manager must ensure that a proper induction package is drawn up for new staff recruited to the home. This should include one to one support and shadowing before staff are asked to work alone in the home. 31/12/05 31/12/05 31/12/05 9. 39. 26 (2) 10. 41. 17 (1) 11. 41. 17 (2) The registered manager must 31/12/05 ensure that Regulation 26 visits are carried out at the home on a regular monthly basis and that copies of these reports are sent to the Commission For Social Care Inspection. The registered manager must 31/12/05 ensure that there is an appropriate procedure for reporting Incidents and Accidents and that all staff are aware of the procedure. The registered manager must 31/12/05 contact the service users appointee to enquire what this sum of money was withdrawn for and request a receipt for the Version 1.40 Page 24 Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc service users financial records. 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 6. Good Practice Recommendations It is recommended that the registered manager seek opportunities for the service user to experience driving in a controlled risk assessed environment i.e. go carting or simulators. As recommended at the last inspection the fact that service users do not wish to attend other social and educational activities outside those offered by the Unicorn Project has been discussed by the service user and registered manager and recorded in their person centred plans. It is recommended that is discussed at the next Person Centred Plan review. It is recommended that the service users bedroom is redecorated. It is recommended that the registered manager ensure that the member of staff employed at the home for over two years completes an appraisal. This will offer guidance to the registered manager when appraising new members of staff when the time comes. It is recommended that timescales for action were included to the Regulation 26 visit format. 2. 13. 3. 4. 24. 35. 5. 39. Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 25 Commission for Social Care Inspection Croydon, Kingston & Sutton 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 Unicorn House (104) G53-G53 S25865 UnicornHouse(104)AI V242146 120905 stage 0.doc Version 1.40 Page 26 - 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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