Inspection on 14/03/07 for Bevan House

This inspection was carried out on 14th March 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bevan House 08/01/08

Bevan House 24/04/06

Bevan House 12/09/05

Bevan House 15/11/04

Bevan House 28/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 O`Hara Key Unannounced Inspection 14th March 2007 08:00 Unicorn House (104) DS0000025865.V332976.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 Unicorn House (104) DS0000025865.V332976.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. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Unicorn House (104) Address Unicorn House 104 Coldharbour Road Croydon Surrey CR0 4DW 020 8726 7811 020 8686 0135 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Maharajah Madhewoo Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 2006 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) DS0000025865.V332976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key unannounced site visit at the home this inspection year. The first key inspection was completed on the 24th of April 2006 and a random unannounced inspection was carried out at the home on the 6th of December 2006. This report includes information from all three inspections. This unannounced visit took place between 8.00am and 10.00am on a Wednesday morning. Methods of inspection included a tour of the premises and discussion with the home manager Mr. Radhakissoon. Records examined included service users person centred plans, care plans, risk assessments, complaints, adult protection, staffing training, medication, and health and safety records. Requirements and recommendations from the previous inspections were also discussed with Mr. Radhakissoon. What the service does well: What has improved since the last inspection? Mr. Radhakissoon works full time Monday through to Friday and occasionally at weekends. The home appears more geared to meeting the service users needs and it was encouraging that he had worked towards improving domestic and social activities for the service users and meeting the requirements set by the Commission. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 6 It is evident that Mr. Radhakissoon is working to develop more opportunities for the service users to involve themselves in the local community. The home now has its own transport enabling more flexibility when offering service users access to the community, attending social activities and day trips out to London and the coast. However in order to develop his independence and life skills one of the service users is encouraged/supported to use public transport to go to the day service and access the local community and Croydon Town centre. Further progress is being made to ensure that service users are appropriately supported with their physical and emotional health needs. The service users are now benefiting from having a well-supported staff team who are receiving supervision with Mr. Radhakissoon at regular intervals What they could do better: The Commission had concerns that the previous registered manager worked at another care establishment while he was also managing 104 Coldharbour Road. The Commission was concerned that not enough emphasis was placed on improving the service, meeting the needs of the service users and meeting the requirements set by the Commission. The previous manager resigned his post at the home in September 2006. The Commission For Social Care Inspection cancelled his registration on the 10th of November 2006. Mr. Radhakissoon started managing the home in September 2006. There have been significant improvements made to the home since Mr. Radhakissoon started managing the home. The overall impression when visiting the home now is that it is well managed and service users are being offered more opportunities to take part in appropriate activities both in and out of the home. In order that the service users and stakeholders can be sure that the service is improving it is important that these improvements are sustained and that Mr. Radhakissoon continues his positive approach to meeting the needs of the service users and meeting the requirements set by the Commission. There were a few area’s identified during the inspection were Mr. Radhakissoon could make further improvements. The safety and welfare of the service users could be compromised if the hot water system in the home is not properly regulated. Mr. Radhakissoon should review and update the current guidelines for staff to support one of the service users with epilepsy. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 7 Mr. Radhakissoon should follow guidance given in Standard 39 of the National Minimum Standards when developing the current quality monitoring system. Staff appraisal should be related to the needs of the service users, the objectives of the home and the training and development needs of the member of staff. The inspector would like to thank the service users and Mr. Radhakissoon for their support during the course of the inspection. 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. Unicorn House (104) DS0000025865.V332976.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 Unicorn House (104) DS0000025865.V332976.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective service users and their representatives with the information they need to make an informed decision about whether or not to use the service. No new service user has moved to the home since the last inspection however all the procedures are in place should they be needed. EVIDENCE: The previous registered manager, Mr. Noruthun resigned his post at the home in September 2006. The Commission For Social Care Inspection cancelled Mr. Noruthun’s registration on the 10th of November 2006. Mr. Premnath Radhakissoon started managing the home in September 2006. No new service user has moved to the home since the last inspection however all the procedures are in place should they be needed. It was stated at the key inspection on the 24th of April 2006 that information included in the home’s Statement of Purpose was misleading and could result in an inappropriate placement being made to the home. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 10 An action plan received by the Commission on 4th July states that irrelevant parts identified in the Statement of Purpose has been updated accordingly. A copy of the updated Statement of Purpose was included. The Statement of Purpose appears to reflect the aims and objectives of the home and the categories under which the home registered by the Commission for Social Care Inspection to provide care. The document included new complaints guidance and reference to the Commission. The document states 104 Coldhabour Road is registered to support younger adults that have a learning disability and associated challenging behaviour. Mr. Radhakissoon is in the process of reviewing the Statement of Purpose to include his own details. The Statement of Purpose no longer indicates that drug therapy is offered in the home. A requirement was set at the key inspection that the registered manager must send a copy of the Service Users Guide to the Commission For Social Care Inspection. A copy of the Service Users Guide was received with the action plan. The Service Users Guide included new complaints guidance, a copy of a service users contract/statement of terms and a copy of Tenancy agreement. However on the 1st of September 2006 the Care Homes Regulations 2001 regarding the Service Users Guide were amended. It is recommended that the Service Users Guide be reviewed in line with the amended regulations. (1) The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include— (a) a summary of the statement of purpose; (b) a description of the standard services offered by the care home to service users; (ba) the terms and conditions (other than those relating to fees) in respect of the provision to service users of accommodation (including the provision of food), personal care and (if available) nursing care; (bb) details of the total fee payable in respect of the services referred to in sub-paragraphs (b) and (ba) and the arrangements for the payment of such a fee; Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 11 (bc) the arrangements in place for charging and paying for any services additional to those mentioned in sub-paragraphs (b) and (ba); (bd) a statement of whether any of the matters mentioned in subparagraphs (b) to (bc) would be different in circumstances where a service user’s care was being funded, in whole or in part, by a person other than the service user; (c) a standard form of contract for the provision of services and facilities by the registered provider to service users; (d) the most recent inspection report; (e) a summary of the complaints procedure established under regulation 22; (f) the address and telephone number of the Commission. (2) The registered person shall supply a copy of the service user’s guide to the Commission and each service user. (2A) If a person other than a service user or the Commission requests a copy of the service user’s guide, or an extract of any of the information contained within it, the registered person shall either— (a) make the service user’s guide available for inspection by that person at the care home; or (b) supply a copy (3) Where a local authority has made arrangements for the provision of accommodation, nursing or personal care to the service user at the care home, the registered person shall supply to the service user a copy of the agreement specifying the arrangements made. During this inspection Mr. Radhakissoon stated that he is working to develop a new Service Users Guide taking into account the new regulations. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 12 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Both service users have service user plans with detailed information on their needs and personal goals. Both service users have individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. EVIDENCE: The action plan included a copy of a letter sent to the service users care manager on the 24th May 2006 regarding development of a programme for independent living skills thus enabling him to use the kitchen in a safe manner and developing social activities. The care manager stated in reply to this letter that he wished to view the service users current programme for independent living skills, and if there Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 13 wasn’t one he would encourage the registered manager to organise one and send it to him as soon as possible. At a random inspection at the home on the 6th of December 2006 Mr. Radhakissoon stated that he had been at the home for three months and he was getting to know the service users. He stated that he planned to develop a weekly activity record, in January 2007, for the service users that would include domestic and social activities. During today’s inspection Mr. Radhakissoon produced a weekly activity record for the service users. Both service users had a Person Centred Plan completed on the 26th of February 2007 the plan includes likes and dislikes, activities, personal care, physical heath needs. One service user had his care plan/placement reviewed on the 7th of April 2006 and the other service users care plan/placement review was completed on the 14th of November 2006. These care plans/placements were reviewed by the service users care managers. One service user had his risk assessments reviewed and updated as appropriate on the 19th of December 2006 and the other service users risk assessments reviewed on the 16th of January 2007. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 14 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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. It is evident that the new home manager Mr. Radhakissoon is working to develop more opportunities for the service users to involve themselves in the local community. Arrangements are made so that all service users have regular contact with their friends and families. EVIDENCE: At the random inspection Mr. Radhakissoon explained that he encourages service users to use public transport to go to the day service and access the local community and Croydon Town centre. He stated that the home will have its own transport early next year enabling more flexibility when offering service users access to the community, attend social activities and day trips out to London and the coast. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 15 It was also noted that one of the service users was able to access the kitchen and make him self a cup of tea. Mr. Radhakissoon discreetly supervised the service user in this task. Mr. Radhakissoon stated that he hoped to build on these activities and review them with the service users care manager at the next review meeting in April 2007. During todays inspection it was observed that the home now has its own transport. Mr. Radhakissoon stated that he and one other member of staff are able to take service users out for drives and to activities in the local community. Mr. Radhakissoon has set a programme in place to support a service user to use public transport. Mr. Radhakissoon stated that the service user has been on the bus twice now and is enjoying the experience. Both service users have regular contact with their families. One service users mother visits occasionally and telephones twice a week the other service users mother contacts him by phone and sends parcels with personal items to him in the post. Food menus were examined and found to be appropriate. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 16 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 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the health care needs of the service users are good and service users receive personal support in the way they prefer. Further progress is being made to ensure that service users are appropriately supported with their physical and emotional health needs. The homes policies and procedures for handling medicines in the home ensure the service users are so far as reasonably practicable protected from harm and/or abuse. EVIDENCE: A requirement was set at the key inspection that the home manager must ensure that there are guidelines for staff to follow in the event of the service user presenting challenging behaviours. This requirement was originally set for 14/09/05 At the random inspection Mr. Radhakissoon produced a set of common guidelines that had been reviewed and agreed and signed by the registered Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 17 provider, the previous registered manager, the staff team and the community nurse from the Croydon Learning Disabilities team. Although there was reference to the service user presenting challenging behaviours it was agreed that these guidelines needed to be more apparent to staff working with this particular service user. Mr. Radhakissoon produced another copy of the guidelines for staff to follow in the event of the service user presenting challenging behaviours. He agreed that these were not appropriate and were in need of reviewing. Mr. Radhakissoon stated that he would review the guidelines and discuss it with and the community nurse from the Croydon Learning Disabilities Team when he visited the service user at the end of the month. During todays inspection Mr. Radhakissoon produced appropriate new guidelines for staff to follow to support the service user with challenging behaviour. These had been drawn up and agreed with the community nurse from the Croydon Learning Disabilities Team. Mr. Radhakissoon produced guidelines for staff to support one of the service users with epilepsy. The previous registered manager had drawn these up. It is recommended that the registered manager review and update if appropriate the current guidelines for staff to support one of the service users with epilepsy. The home employs the Boots blister pack system to obtain and dispense medication. It was recommended at the key inspection that the previous registered manager contact Boots the pharmacist and arrange a visit to the home to offer advice on medication. At the random inspection Mr. Radhakissoon produced a document as evidence that the Boots pharmacist had visited the home on the 17th of July 2006 and offered advice to the home about its medication system. The home has a record of receipts of medication and medication stock checks are carried out weekly. However the home does not have a record for returns of medication. It is recommended that the registered manager develop a system for recording returns of medication. Both service users are registered with a local General Practitioner. The service users wishes on how they are supported with personal care are outlined in detail in their Person Centred Plans. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 18 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 and 23. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home has appropriate complaints procedure in place. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure the service users are so far as reasonable practicable protected from abuse, neglect and/or harm. EVIDENCE: At the key inspection staff records indicated that all staff attended Protection of Vulnerable Adults training. A requirement was set at the random inspection that the new home manager and staff must attend training on Croydon Councils Protection of Vulnerable Adults Procedure. Mr. Radhakissoon attended Croydon Councils Protection of Vulnerable Adults Procedure training on the 27th of February 2007. Mr. Radhakissoon was advised to obtain a copy of Croydon Councils Protection of Vulnerable Adults Procedure. During todays inspection Mr. Radhakissoon produced a booklet obtained from the adult protection training however this was not Croydon Councils Protection of Vulnerable Adults Procedure. Mr. Radhakissoon stated that he would contact Croydon and request a copy of their procedures. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 19 The home has a book for recording complaints Mr. Radhakissoon stated that there have been no complaints made to the home by the service users, staff or by any other persons since he commenced employment. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 20 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 and 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 homely and comfortable environment. However the safety and welfare of the service users could be compromised if the hot water system in the home is not properly regulated. EVIDENCE: At the random inspection Mr. Radhakissoon pointed out that one of the service users has moved to another room upstairs in the home. The service user said that he liked this room better, he seemed more comfortable and relaxed than on previous visits. The other service users bedroom has been re carpeted and redecorated. At the key inspection an immediate requirement notice was handed to the previous registered manager that he must ensure that the facilities at 106 Coldharbour Road must not be used as a care home. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 21 The action plan stated that no facilities at 106 Coldharbour Road are used as a care home. The office is being used for admin purposes. During the random inspection it was noted that the door between 104 and 106 Coldharbour Road was locked. Mr. Radhakissoon showed the inspector into 106 Coldharbour Road and confirmed that no part of the home including the office is in use. Mr. Radhakissoon stated that staff use the small office in 104 Coldharbour Road for administration purposes. It was evident that staff at the home is using the office in 104 Coldharbour Road. At the random inspection Mr. Radhakissoon enquired when it would be likely that the Commission would consider an application by the registered provider to register 106 Coldharbour Road. It was explained that the registered provider had agreed certain conditions with the Commission For Social Care Inspections legal representatives following his appeal to the Care Standards Tribunal. These conditions were that the registered provider appoints a full-time manager with no other employment commitments to run 104 Coldharbour Road. The new manager should have at least two years’ significant management or supervisory experience in the past five years in a relevant care setting, namely with service users with learning disabilities, and with qualifications (or currently completing qualifications) at level 4 NVQ in both management and care. The registered provider should ensure the submission of an application by the new manager to the Commission to be registered as manager of the 104 Coldharbour Road. At the random inspection Mr. Radhakissoon stated that he has experience working as a deputy manager at Prema House and residential care home in Streatham. He is currently completing level 4 NVQ in both management and care at the Ability Training Centre in Sidcup. During today’s inspection Mr. Radhakissoon stated that he is due to start the Registered Managers Award in May 2007. Another condition was that the registered provider acknowledges that the care home is registered to support people with learning disabilities; service users with mental health needs must not be admitted to the care home. Another condition was that the registered provider undertakes to meet all outstanding requirements from the inspection carried out at the care home on 24 April 2006; and to ensure that the door leading from the care home to the adjacent premises at 106 Coldharbour Road is at all times kept locked, and that the premises at 106 Coldharbour Road are not used in any capacity for or in relation to the day-to-day running of the care home. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 22 It was established during the random inspection that almost all of the outstanding requirements from the inspection carried out at the care home on 24th April 2006 have been met. During today’s inspection it was evident that Mr. Radhakissoon is working to improve the services offered to the service users at the home. The door leading from the care home to the adjacent premises at 106 Coldharbour Road was observed to be locked during today’s inspection. Mr. Radhakissoon stated that the premises at 106 Coldharbour Road are not used in any capacity for or in relation to the day-to-day running of the care home. The Commission has agreed that, when the registered provider had fully complied with all of the above terms to its satisfaction, it would consider a fresh application by the registered provider for the premises at 106 Coldharbour Road to be registered as part of the care home and for the number of service users at the care home to be increased appropriately. It was noted today that the hot water in the bathroom reached 48 C. The registered manager must ensure that the home water temperature is regulated to reach 43 C maximum. The registered manager should seek advice from a reputable plumber and have thermostat mixer valves installed at all sinks and bathrooms. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 23 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): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a small staff team and all documentation required through the homes recruitment and selection process is available in the home for inspection. The service users are now benefiting from having a well-supported staff team who are receiving supervision with the manager at regular intervals. EVIDENCE: A requirement was set at the key inspection that the registered manager must support the member of staff to complete the full induction. The action plan stated that the member of staff had already completed a full induction and that the manager would provide continuous training, coaching and support. At the random inspection Mr. Radhakissoon produced the member of staffs induction workbook. Most of the workbook had been completed and signed by the member of staff and the previous manager, however one section had Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 24 been signed by the previous manager and not the member of staff. Mr. Radhakissoon said that he would go over this again with the member of staff. It was recommended at the random inspection that staff appraisal be related to the needs of the service users, the objectives of the home and the training and development needs of the member of staff. Mr. Radhakissoon stated that he and the acting home manager at Unicorn House, Mr Jay Venkaya, had developed a new appraisal system to be introduced to staff in both services early next year. During todays inspection Mr. Radhakissoon stated that this appraisal system had not been introduced. He stated that the home and the other home had employed the services of a company by the name of Peninsula to introduce health and safety and staffing procedures. He stated that Peninsula was developing an appraisal system format for both of the homes. It was recommended at the key inspection that all staff attend training on moving and handling. On the day of the random inspection Mr. Radhakissoon contacted Unicorn Projects Training Centre and confirmed that staff would attend moving and handling training on the 18th of December 2006. During todays inspection Mr. Radhakissoon produced evidence that all staff had attended moving and handling training. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 25 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, 39 and 42. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. There have been significant improvements made to the home since that last inspection. The overall impression when visiting the home is that it is well managed and service users are now being offered more opportunities to take part in appropriate activities both in and out of the home. EVIDENCE: Following the key inspection an immediate requirement notice was handed to the previous manager that he must ensure that the fire door leading to the kitchen is not tied open. A requirement was also set at the key inspection that previous manager contact the London Fire & Emergency Planning Authority to review the homes Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 26 practices regarding fire safety. An automatic release mechanism connected to the fire alarm system must be fitted to the kitchen door. It was noted during the random inspection that the fire door leading to the kitchen was held open by an automatic release mechanism connected to the fire alarm system. A requirement was set at the key inspection that the registered manager must inform the Commission when the homes fire alarm system is repaired. At the random inspection Mr. Radhakissoon produced a document from London Fire Services that the fire alarm system had been repaired on the 11th May 2006. The same company carried out a check on the homes fire equipment on the 29th of September 2006. A requirement was set at the key inspection that the previous registered manager must ensure that regular checks take place in the home so that food past their best before date is not offered to the service users. At the random inspection Mr. Radhakissoon produced evidence that food checks are conducted on a daily basis. The food in the fridge and freezer was inspected and all food stuffs were within their best before date. An action plan, 4th July 2006, stated that members of staff have been instructed to conduct food checks on a daily basis and a new system is in place. It was recommended at the key inspection that the previous registered manager access the Commissions website: www.csci.org.uk to find out about Inspecting for Better Lives 2 and the Commissions new inspection procedures. At the random inspection Mr. Radhakissoon said that he is aware of Inspecting for Better Lives 2 and the Commissions new inspection procedures. He also said that he is able to access the Commissions website when he feels the need. It was recommended at the key inspection that the previous registered manager follow guidance given in Standard 39 of the National Minimum Standards when developing the current quality monitoring system. Mr. Radhakissoon has yet to address this recommendation but said that he would look at Standard 39 of the National Minimum Standards when developing the homes quality monitoring system. An additional visit was carried out at the home on the 16th March 2006. The reason for the visit was to review a number of requirements set at the previous inspection on the 12th of September 2005, Requirement 9 from that visit was outstanding. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 27 This required that the registered manager ensured 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. During the additional visit on the 16th March the previous registered manager, Mr. Noruthun, stated that Regulation 26 visits had not been carried out at the home for February and March because the registered manager for Unicorn House had resigned. On the 16th March 2006 an immediate requirement was served that the registered provider ensure that Regulation 26 visits are carried out on the home on a regular monthly basis and these reports are sent to the Commission. At the random inspection Mr. Radhakissoon stated that no regulation visits had been carried out at the home since July 2006. He was advised that Regulations 26 visits should be carried out by the registered provider in order to inspect the premises of the care home, its record of events and records of any complaints, form an opinion of the standard of care provided in the care home and prepare a written report on the conduct of the care home. A warning letter was sent to the registered provider on the 22nd January 2007 because regulations 26 of the care homes regulations had been persistently breached. The registered provider was required to; Ensure that as of the date of the letter regulation 26 visits are carried out at both 104 Coldharbour Road and his other care home at 16 Campden on a monthly basis. Regulation 26 reports have been received at the Commission for January and February 2007. During todays inspection Mr. Radhakissoon produced completed service user surveys that included their opinions about the service provided in the home. It is recommended that the registered manager also seek the views of service users relatives, care managers, General Practitioners, and staff about the service provided in the home. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 28 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 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 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 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 29 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 YA42 Regulation 13 (4) a Timescale for action The registered manager must 15/03/07 ensure that the home water temperature is regulated at 43 C. The registered manager should seek advice from a reputable plumber and have thermostat mixer valves installed at all sinks and bathrooms. Requirement 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 YA35 Good Practice Recommendations It is recommended that staff appraisal be related to the needs of the service users, the objectives of the home and the training and development needs of the member of staff. It is recommended that the registered manager follow guidance given in Standard 39 of the National Minimum Standards when developing the current quality monitoring system. It is recommended that the Service Users Guide be reviewed in line with the amended regulations. It is recommended that the registered manager review DS0000025865.V332976.R01.S.doc Version 5.2 Page 30 2. YA39 3. 4. YA1 YA18 Unicorn House (104) 5. YA20 and update if appropriate the current guidelines for staff to support one of the service users with epilepsy. It is recommended that the registered manager develop a system for recording returns of medication. Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Unicorn House (104) DS0000025865.V332976.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!