Inspection on 24/04/06 for Bevan House

This inspection was carried out on 24th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 25 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 14/03/07

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 24th April 2006 07:50 Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 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.V290100.R01.S.doc Version 5.1 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.V290100.R01.S.doc Version 5.1 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 Dhaneshwur Noruthun Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 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) DS0000025865.V290100.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. Methods of inspection included formal and informal interviews with the service users and discussion with the registered manager Mr. Noruthun. Records examined included staffing records, care plans, person centred plans, menu’s, the home’s Statement of Purpose, fire records, risk assessments, health care correspondence, medication records, complaints records, visitor’s book and outstanding requirements action plans. Evidence gathered from correspondence to the Commission, a meeting with Mr. Noruthun at the Commission 22nd December 2005 and an additional visit/inspection carried out at the home on the 16th March 2006 have been used to complete this inspection report. What the service does well: What has improved since the last inspection? What they could do better: Since the last inspection carried out in September 2005 the registered manager Mr. Noruthun has met all but two of the requirements. On the 16th March 2006 an additional inspection visit was carried out and six further requirements including two immediate requirement notices were served to the home. As a result of this inspection fourteen requirements have been set including two more immediate requirement notices, eleven requirements are Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 6 new, six new recommendations have also been set. The management and quality assurance monitoring within the home needs to be more consistent to ensure a continuous programme of improvement that benefits the residents. The quality and accuracy of all information requested or sent to the Commission by Mr Noruthun needs to be accurate and not misleading. Continued failure to maintain the high standards of integrity expected of a registered manager could result in the fitness of the manager being brought into question. Following the additional inspection visit carried out at the home on the 16th March 2006 an action plan was sent to the Commission stating that some of the requirements had been met however during this inspection Mr. Noruthun was not able to provide any evidence that this was the case. Also information included in the home’s Statement of Purpose is misleading and could result in an inappropriate placement being made to the home. Service user care plans/Person Centred Plans include detailed information on their needs and personal goals. However more could be done to by the home to ensure that they are supported to develop independent living skills and access social activities in the wider community. Although service users said that they are happy with food provided the home should take more care so as to ensure that food past their best before date is not offered to the service users. Mr. Noruthun should attend Protection of Vulnerable Adults training so that service users can be sure that the whole staff team know what to do to protect them from abuse and neglect. Although service users live in a homely and comfortable environment their safety and welfare could be compromised if Mr. Noruthun does not make suitable arrangements for fire safety and continues to allow service users and staff to use the next door premises as part of the care home. The inspector would like to thank the service users and Mr. Noruthun support on the day 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. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Information included in the home’s Statement of Purpose is misleading. This could result in an inappropriate placement being made to the home. EVIDENCE: The home Statement of Purpose was examined. The Statement of Purpose indicated that the home provides support to people with learning disabilities and associated mental health. The home is registered by the Commission to support three people with learning disabilities only. If Mr. Noruthun, wishes to admit service users with learning disabilities who also have an associated mental health condition an application to vary the home’s category of registration will need to be sought. The Statement of Purpose indicates that the home supports twelve service users however the home is registered by the Commission to support three people with learning disabilities. The Statement of Purpose indicates that the home offers therapeutic activities as well as drug therapy. Mr. Noruthun was unable to explain the nature of the therapies he was offering in the home, or whether he or his staff were qualified to offer such services. Mr Noruthun admitted he had not responsible for the drafting of the Statement of Purpose Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 9 Mr. Noruthun stated that the Statement of Purpose was sent to the registered provider to be reviewed. Despite being responsible for the home Mr Noruthun was unable to explain why he had not challenged these inclusions. Mr. Noruthun was advised that he had a responsibility as the registered manager to ensure the home’s Statement of Purpose accurately reflected the home’s category of registration and that the staff were suitably qualified, competent and experienced. The registered manager must seek clarification from the registered provider what service the home is seeking to provide and inform the Commission of any changes which will require a variation or new training for staff. The Statement of Purpose must also accurately reflect the aims and objectives of the home and the categories under which the home registered by the Commission. Mr. Noruthun was advised that the Statement of Purpose should indicate the Commission For Social Care Inspections new complaints guidance in the homes complaints procedure section. No new service user has moved to the home since the last inspection however all the procedures are in place should they be needed. Following examination of previous regulation 26 visit reports sent to the Commission it was identified that the home did not have a Service Users Guide. The registered manager must send a copy of the Service Users Guide to the Commission. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Service user care plans/Person Centred Plans include detailed information on their needs and personal goals. However more could be done to by the home to ensure that service users are supported to access social activities in the wider community and develop independent living skills. The home is failing to ensure that risk assessments are carried out regarding the service user using the kitchen thereby putting them at risk of an accident. EVIDENCE: It was noted during a visit to the home on the 16th March 2006 that the kitchen door was tied/held open with an apron. The member of staff on shift and Mr. Noruthun stated that this was as a result of a service user becoming gets upset if the door was not left open. It was recommend that Mr. Noruthun contact the service user’s care manager to develop a programme for independent living skills which would remove the necessity to keep the door the tied open and hopefully enable him to use the kitchen in a safe manner. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 11 An action plan was received at the Commission on the 4th April 2006 that indicated that the service user was going to have his care plan reviewed on the 7th April 2006. Following this a care plan would be drawn up to enable the service user to use the kitchen in a safe manner. During this inspection it was observed that the kitchen door was again tied/held open with an apron. Mr. Noruthun stated that he and the staff only did that in the mornings. Mr Noruthun was advised that as this was a fire door it should not be tied open at any time, Mr. Noruthun replied that he continues to tell the staff not to do this. It was pointed out to Mr. Noruthun that he was also culpable as he was the only person on shift that morning. An immediate requirement notice was handed to Mr. Noruthun that as the Registered Manager he must ensure that the fire door leading to the kitchen is not tied open. Mr. Noruthun produced minutes from the service users care plan review meeting. It was noted that some of the wording in the minutes could be construed as derogatory towards the service user. Mr. Noruthun was advised to consider the wording of future meeting minutes. There was no evidence in the minutes to indicate that a programme for independent living skills enabling the service user to use the kitchen in a safe manner had been discussed. Mr. Noruthun stated that these minutes had been drawn up before the meeting took place and assured me that the programme for independent living skills had been discussed but he was waiting for the care plan to be returned by the service users care manager. Following the inspection, on the 26th March 2006, the service users care manager was contacted by telephone and asked if a programme for independent living skills enabling the service user to use the kitchen in a safe manner had been discussed at the review meeting. The care manager advised that the theme of the meeting was around the needs of the service user in the home, the day service and accessing the wider community but that there was no specific discussion about the service user having an independent living skills programme for using the kitchen. A recommendation was set following the visit on the 16th April 2006 that Mr. Noruthun carry out and record a risk assessment regarding holding the door open when the service user was using the kitchen. Mr Noruthan confirmed in an action plan sent to the commission that the risk assessment had been in place prior to the visit on the 16th which would have been available if the inspector had requested to see it. However, when asked, he was unable produce the risk assessment and following further enquiries admitted that this had not been undertaken. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Although provision is made so that service users attend day centres and become part of the local community more could be done to by the home to ensure that one of the service users is supported to access social activities in the wider community and develop independent living skills. Appropriate arrangements are made so that all service users have regular contact with their friends and families. Although service users said that they are happy with food provided, the home should take more care so as to ensure that food past their best before date is not offered to the service users. EVIDENCE: Mr. Noruthun showed evidence that he is completing one of the service users Person Centred Plans. One service user has indicated that he does not wish to attend other social and educational activities outside those offered by the Unicorn Project. This had been discussed by the service user and Mr. Noruthun and recorded in the service users person centred plans. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 13 To evidence this Mr. Noruthun asked the service user a number of questions about activities, for instance did he want to go to the cinema or a visit to the airport The service user said no to both suggestions. However following discussions Mr Noruthun agreed that a more flexible and creative approach to introducing activities may be more sucessful than taking at face value the answers to a direct question. Mr. Noruthun said that the service user has gone with him to the café in the Croydon Clock Tower on a number of occassions lately and that he could see that he could build on this. The registered manager must contact the service users care manager in relation to how staff at the home develop social activities and how these are presented to the service user. During the telephone converstaion with the service user’s care manager he indicated that activities in the wider community were discussed at the care plan review and these would be monitored in the future. During the inspection the Community Learning Disability Nurse visited one of the service users at the home. He said that he would work with manager and staff around the service users challenging needs and possible therapeutic activities inside and outside of the home. It is recommended that is discussed at the next Person Centred Plan review. Both service users said that they are happy living at the home and both said that they like going to the day service. One service user said that he works at the Scope charity shop on Wednesdays. One service user said that he has regular telephone contact with his mother and that she sometimes comes to see him at the house. Food menus were examined and found to be appropriate. However upon inspection of the fridge two steak and kidney pies were found to be seven days past their best before date. Mr. Noruthun removed the pies and placed them in the bin. The 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. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Service users appeared to be appropriately dressed and service users said they receive personal support in the way they prefer. Progress is being made to ensure that service users are appropriately supported with their physical and emotional health needs. Recording of medication systems has improved and administration records were recorded accurately. EVIDENCE: A requirement was set at the last inspection that the home’s 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. During the inspection the Community Learning Disability Nurse visited one of the service users at the home. He said that he would work with manager and staff around the service users challenging needs and also advise the home on guidelines for the support of this service user should he have an epileptic seizure. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 15 During a meeting at the Commission For Social Care Inspection office on the 22nd of December 2005 Mr. Noruthun was advised to ensure that the home has a robust record of reciepts and returns of medication and that medication stock checks should be carried out weekly. The home has a record of reciepts and returns of medication and medication stock checks are now carried out weekly. The home employs the Boots blister pack system to obtain and dispense medication. The home has a contract with Boots pharmacy. The contract states that the Pharmacist will complete an initial visit to the home to offer advice on medication however Mr. Noruthun stated that the pharmacist has not yet visited the home. It is recommended that the registered manager contact Boot’s pharmacist and arrange a visit to the home to offer advice on medication. Service users appeared to be appropriately dressed and both service users said they receive personal support, if needed, in the way that they preferred. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has an appropriate complaints procedure however the procedure should be updated to reflect the Commission’s new guidance on complaints and concerns. The registered manager should attend Protection of Vulnerable Adults training so that service users can be sure that the whole staff team know what to do to protect them from abuse and neglect. 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 attended Protection of Vulnerable Adults training however Mr. Noruthun stated that has not yet had training for the Protection of Vulnerable Adults. The registered manager must attend training on Croydon Councils Protection of Vulnerable Adults Procedure. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Service users live in a homely and comfortable environment. However the safety and welfare of the service users could be compromised if the registered manager does not make suitable arrangements for fire safety and continues to allow service users and staff to use the next door premises as part of the care home. EVIDENCE: It was noted during a visit to the home on the 16th March 2006 that the kitchen door was tied/held open with an apron. During this inspection the kitchen door was again tied/held open with an apron. As previously stated in this report an immediate requirement notice was handed to Mr. Noruthun that he must ensure that the fire door leading to the kitchen is not tied open. A requirement was set following the visit to the home on the 16th March that the registered manager must seek advice from London Fire & Emergency Planning Authority for advice on the type of door in the kitchen i.e. is it an appropriate fire door. Mr. Noruthun produced two letters from London Fire & Emergency Planning Authority, the first letter 10/05/05 contained recommendations including the upgrading of glazing to the one-hour fire door and the fitting of a self-closing Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 18 device. The second letter 08/06/05 stated that the premises were found to be satisfactory. Although a self-closing device had been fitted the door is still being tied open. Mr. Noruthun pointed out that the adjoining door leading to 106 Coldharbour Road had an automatic door release mechanism that was activated by the homes fire alarm system. In order to demonstrate how this worked Mr. Noruthun produced a key to carry out a check on the homes fire alarm system. He inserted the key into the break glass call point in the lounge but the alarm failed to activate. After three more attempts the alarm still failed to activate. Mr. Noruthun stated that door mechanism can also be activated by vibration and demonstrated this by hoovering next to the door until the mechanism was activated and the door closed. Given the current fire safety practice’s employed at 104 Coldharbour Road the registered manager must contact the London Fire & Emergency Planning Authority to review the homes practices regarding fire safety. An automatic release mechanism connected to the fire alarm system must be fitted to the kitchen door. During the inspection Mr. Noruthun contacted the company that installed the fire alarm system and made arrangements for an engineer to visit the home and repair the system. The registered manager must inform the Commission when the homes fire alarm system is repaired. A requirement set at the visit on the 16th March 2006 (As of the date of this letter the registered manager must ensure that the facilities at 106 Coldharbour Road are not used as a care home). An action plan from Mr. Noruthun was received at the Commission office on the 4th April 2006 stating that Facilities at 106 Coldharbour Road are not used as a care home except the office as there was no space for office in 104 Coldharbour Road. Mr. Noruthun also stated during this inspection that 106 Coldharbour Road is not used as part of the care home. However during the inspection the Community Learning Disability Nurse came to meet with a service user. The service user went through the open adjoining door to 106 and after a brief discussion with the inspector, the Community Learning Disability Nurse was led by Mr. Noruthun into 106 to convene the meeting. Mr. Noruthun later stated that he did this, as there was no available private or communal space in 104 to conduct the meeting an immediate requirement notice was handed to Mr. Noruthun that he must ensure that the facilities at 106 Coldharbour Road must not be used as a care home. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 19 Mr. Noruthun was reminded that during previous inspections prior to 106 Coldharbour Road being available for use, the sleepover room in 104 or the residents own bedrooms had been used to meet with them. Both service users showed the inspector their bedrooms; one service user said that his bedroom had been redecorated since the last inspection. The service users bedrooms appeared comfortable and clean. The home was clean throughout and free off offensive odours. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. 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 staff induction training needs to be fully completed by staff so that they can confidently meet the needs of the service users. CRB checks are now held at the home. This will allow the Commission to check that staff vetting is occurring properly and facilitate the protection of the residents. EVIDENCE: It was noted at the last inspection on the 12/09/2005 that a new member of staff started work in the home. His first day was for induction only which lasted from 8.30am till 11am. This was undertaken with Mr Noruthun. Although having no previous experience of working with people with learning disabilities he was within three days of starting employment working alone with service users on a late sleepover early shift. A requirement was set that the registered manager must ensure that a proper induction package is drawn up for all new staff recruited to the home which includes one to one support and shadowing before staff are asked to work alone in the home. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 21 However Mr. Noruthun provided evidence that this member of staff was given another more thorough induction. However records show that induction remains an ongoing process for this member of staff. The registered manager must support the member of staff to complete the full induction. It was noted that all staff receive regular monthly supervision. One member of staff is completing an appraisal. The appraisal appeared to show little in relation to the needs of the service users, the objectives of the home or the training and development needs of the member of staff. It is recommended that the appraisal be related to the needs of the service users, the objectives of the home or the training and development needs of the member of staff. Staff attended training on health and safety and fire awareness, food hygiene, first aid, protection of vulnerable adults, medication, epilepsy, non-violent crisis intervention and mental health. It is recommended that all staff attend training on moving and handling. All staff has a contract of employment contained in their files and Criminal Records Bureau Checks were seen for all members of staff at the last inspection. During the meeting at the Commission office on the 22/12/05 Mr. Noruthun provided evidence that a requirement relating to the homes Lone Working Policy and the homes roster indicating who is on call had been met. Mr. Noruthun was advised that wherever possible he must ensure that all staff references are requested on the referees company headed paper and or include a company stamp. No new member of staff has started work at the home since the last inspection. Mr. Noruthun provided evidence to meet the requirement that he obtain two written references for the new member of staff from his previous employers or from the college where he is a student. . Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. The Commission continues to have concerns relating to the registered manager and the proprietor’s management of 104 Coldharbour Road which if continued could lead to reduced life opportunities and increased risk to their health and safety. EVIDENCE: As referred to in previous inspection reports the Commission for Social Care Inspection continues to have concerns that Mr. Noruthun works at another care establishment while he is also the registered manager for 104 Coldharbour Road. The Commission believes that this arrangement has had a negative impact on the way the service has been managed. On the 22/12/05 the Commission For Social Care Inspection invited Mr. Noruthun to the Commission’s office to discuss concerns regarding his management of 104 Coldharbour Road and how he was intending to address outstanding requirements. Part of the meeting also discussed his role as a registered manager Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 23 and his responsibilities to the Commission and the necessity to operate at all times with honesty and integrity. These concerns followed a number of misleading statements from Mr. Noruthun to the Commission that he no longer worked full or part time at any other registered setting other than 104 Coldharbour Road. The Commission accepted his statement However Mr. Noruthun has confirmed that he continues to work on a part time basis at another care establishment. There have been other misleading statements previously mentioned in other sections of the report in respect of: action taken to ensure fire doors have not been tied open; the production of risk assessments and programmes for living skills. Mr. Noruthun was reminded that recording false and misleading representations in any action plan sent to the Commission was not the appropriate actions expected from a registered manager. A requirement was set at the last inspection that the registered manager must ensure that monthly visits to the home are carried out by a person who is not in day to day management of the service. These visits are intended to idependently assess how the service is performing by talking to staff and residents and inspecting the environment. A written report is expected to be produced and made available to the proprietor and the Commission. Failure to carry out these visits and produce a report is a breech of Regulation 26. Mr Noruthun was reminded to ensure these reports were produced at a meeting on the 22/12/05. However during the visit to the home on the 16th March 2006 an immediate requirement notice was handed to Mr. Noruthun as a result of these visits not taking place. Since this issuing of this legal notice reports are now being received on a monthly basis. Mr. Noruthun produced evidence that service users are offered opportunities to comment on the service provided by the home. He was advised of the change of approach the Commission was promoting in seeking views from service users about their experiences of residential care and how this approach would alter the way the Commission would inspect the home in the future. Mr Noruthan was recommended to access the Commission’s website: www.csci.org.uk to find out about Inspecting for Better Lives and the Commissions’ new inspection procedures. It was also recommended that the he follow guidance given in Standard 39 of the National Minimum Standards when developing the current quality monitoring system. The adjoining premises to 104 Coldharbour Road (106) have been purchased by the provider Mr Madhewhoo in order to increase the size of 104 Coldharbour Road. As part of this development an internal door has been put in place to allow access between both properties. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 24 However, the Commission has proposed to refuse this application. Until this issue of registration has been resolved, it means that 106 Coldharbour Road cannot be used in any way as a care home. At the previous visit in March as part of the inspection, 106 Coldharbour Road was visited to ensure that it was not being used. It was noted that the Registration Certificate for 104 Coldharbour Road was affixed to the lounge wall in 106 Coldharbour Road. This was illegal as it could be misinterpreted that the rooms in 106 Coldharbour Road had been registered for use. An immediate requirement notice was served on the Manager that the Certificate of Registration issued in respect of 104 Coldharbour Road should be kept affixed in a conspicuous place in 104 Coldharbour Road. It was observed during this inspection that the Certificate of Registration was displayed in 104 Coldharbour Road. A requirement was also made that 106 Coldharbour Road should not be used for the purposes of a care home. However at this inspection it was evident that Mr. Noruthun continues to allow staff and service users to use the lounge area on these premises. As previously stated in this report an immediate notice was handed to Mr. Noruthun that he must ensure that the facilities at 106 Coldharbour Road must not be used as a care home. A requirement was set at the last inspection that the registered manager must ensure that there is an appropriate procedure for reporting Incidents and Accidents and that all staff are aware of the procedure. Mr. Noruthun produced the current procedure for reporting Incidents and Accidents. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 25 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 1 2 N/A 3 1 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 2 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 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 2 X X 1 X Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 26 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 YA1YA1. Regulation 4(1) Requirement Timescale for action 30/06/06 2. YA1YA1. 4(1) 3. YA1YA1. 4(1) 4. YA2YA2. 14(2)a&b If the registered manager, Mr. Noruthun, wishes to admit service users with learning disabilities and associated mental health conditions to the home then he must contact the Commission and apply for a variation to the homes category of registration. The registered manager must 30/06/06 seek clarification from the registered provider as to why the homes Statement of Purpose states that drug therapy is offered in the home. If drug therapy is employed in the home what are the training requirements for staff. The registered manager must 30/06/06 ensure that the Statement of Purpose accurately reflections 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 registered manager must 30/06/06 contact the service users care manager to develop a programme for independent DS0000025865.V290100.R01.S.doc Version 5.1 Unicorn House (104) Page 27 5. YA42YA42. 23(4)b 6. YA42Ya42. 13(3) 7. YA12YA12 12(3) 8. YA23Ya23 10(3) 9. YA42YA42. 23(4)c 10. YA42YA42. 23(4)c 11. YA42YA42 23(1)a 12. 13. YA33Ya33 YA19YA19 18(1) c 18 (1) c living skills thus enabling him to use the kitchen in a safe manner. An immediate requirement notice was handed to Mr. Noruthun that the Registered Manager must ensure that the fire door leading to the kitchen is not tied open. The 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. The registered manager must contact the service users care manager in relation how staff at the home develop social activities and how these are presented to the service user. The registered manager must attend training on Croydon Councils Protection of Vulnerable Adults Procedure. The registered manager must contact the London Fire & Emergency Planning Authority to review the homes practices regarding fire safety. An automatic release mechanism connected to the fire alarm system must be fitted to the kitchen door. The registered manager must inform the Commission when the homes fire alarm system is repaired. An immediate requirement notice was handed to Mr. Noruthun that he must ensure that the facilities at 106 Coldharbour Road must not be used as a care home. The registered manager must support the member of staff to complete the full induction. The home manager must ensure that there are guidelines for staff DS0000025865.V290100.R01.S.doc 25/04/06 25/04/06 30/06/06 30/06/06 25/04/06 25/04/06 25/04/06 30/06/06 30/06/06 Page 28 Unicorn House (104) Version 5.1 14. YA1YA1. 5(1) to follow in the event of the service user presenting challenging behaviours. This requirement was originally set for 14/09/05 The registered manager must send a copy of the Service Users Guide to the Commission For Social Care Inspection. 30/06/06 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 YA1YA1. Good Practice Recommendations Mr. Noruthun was advised that the Statement of Purpose should indicate the Commission For Social Care Inspections new complaints guidance in the homes complaints procedure section. It is recommended that the registered manager contact Boots the pharmacist and arrange a visit to the home to offer advice on medication. 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 all staff attend training on moving and handling. It is recommended that the 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. 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. 2. 3. YA20Ya20. YA35Ya35. 4. 5. YA35Ya35. YA37Ya37. 6. YA39Ya39. Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Unicorn House (104) DS0000025865.V290100.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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