Inspection on 20/04/06 for Prosignia Ltd

This inspection was carried out on 20th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

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

CARE HOME ADULTS 18-65 Prosignia Ltd 14 Church Lane Avenue Coulsdon Surrey CR5 3RT Lead Inspector Mary Williamson Unannounced Inspection 20th April 2006 10:00 Prosignia Ltd DS0000065332.V291284.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 Prosignia Ltd DS0000065332.V291284.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. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Prosignia Ltd Address 14 Church Lane Avenue Coulsdon Surrey CR5 3RT 0208 688 2617 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) Prosignia Ltd Nreeteshwar Mahadawoo Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is a new service. Brief Description of the Service: Church Lane Avenue is a detached bungalow situated in a residential road on the outskirts of Coulsdon Village. It is within close proximity of a public bus service and the railway station. The home is registered for two service users with a learning disability. Facilities include two en-suite bedrooms, comfortably furnished lounge, wellequipped kitchen, quite room, laundry facilities and a well-maintained back garden. There are parking facilities to the front of the property. The home is newly registered there are currently no service users living there. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for this service following registration in October 2005. Mary Williamson who is the Lead Inspector for the service undertook the inspection. The Provider Mr Mohammed Nunhuck and Company Director Mr Yasin Lilani were present throughout the inspection. There are currently no service users living in the home. The provider informed the inspector that he is currently assessing prospective service users with a view to admission within the next month. A general discussion took place with regard to the admission process and aspirations of the prospective service users. A tour of the premises was undertaken and the home has been decorated to a high standard and well equipped. A wide range of documents to be used for the care of the service users and the management of the home were seen and found satisfactory. The health and safety manual, which includes a wide range of policies and procedures, was seen and found to promote the welfare of prospective service users. Staff have been recruited and will take up post a week prior to the admission of service users, therefore it was not possible to speak with them. The inspector would like to thank The Provider and The Director for their positive contribution and input to the inspection process. What the service does well: The service has made the best possible start in developing the home to accommodate prospective service users. The accommodation is bright and comfortable with new fixtures, fittings, and furniture provided throughout the home. The management has made a good effort in establishing a wide range of policies, procedures, and documents required for the management of the home. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Prosignia Ltd DS0000065332.V291284.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 Prosignia Ltd DS0000065332.V291284.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, 4, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The statement of purpose and service users guide is in place. The admission procedure the service has developed is robust to safeguard the welfare of the prospective service users to the home. EVIDENCE: The provider has developed a statement of purpose and service users guide, which is available to all prospective service users on the initial enquiry to the home. This is also available in symbol format. The provider has also developed a detailed needs assessment format known as “PCS” to be used as the needs assessment tool for all prospective service users. A staggered admission plan is in place ranging from several short visits to a weekend, prior the initial placement being made. A sample of the service user contract to be used was seen and this includes the fee range, the accommodation to be occupied and the care and activities to be provided. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 9 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): These standards were not inspected at this visit, as there are no service users living in the home. EVIDENCE: Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 10 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): The above standards were not assessed, as there are no service users living in the home. EVIDENCE: Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 11 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): 19, and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to meet the physical, health and medical need of the prospective users. EVIDENCE: The provider has made arrangements to have both service users registered with a local GP in Old Coulsdon. Dental treatment has been arranged at The East Surrey Hospital Special needs dental suite or at The Dean Hospital in Caterham if preferred. A local optician in Caterham will provide yearly eye tests, and psychiatric support is available at The Kingsfield Resource Centre. The provider has produced a medication policy and procedure for the home. Medication will be provided by Zena pharmacy in Kenley who will also undertake training and medication audits. Self- administration risk assessments will be developed on an individual basis. The home must provide a secure medication storage unit for all medicines kept in the home. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There home’s policies on complaints and abuse awareness have been developed to protect prospective service users. EVIDENCE: The home has a complaints procedure in place, which is also included in the service user guide. This will be available to all service users on admission to the home. There is also a copy of Surrey’s Multi- Agency Procedures on the Protection of Vulnerable Adults in place. The provider has attended training in these procedures and has also developed an abuse awareness policy for the home. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 13 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, 26, and 27. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides a comfortable, well- decorated environment with ample communal space and en-suite bedrooms. EVIDENCE: The home has been adapted to provide a small comfortable environment for two prospective service users. The standard of decoration is good throughout the home. Accommodation consists of two en-suite bedrooms, a bright well -decorated lounge, a wellequipped kitchen, a small quite room, laundry facilities, and an office. There is a large garden to the rear of the property and car parking facilities to the front. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 14 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 Currently there are no staff working in the home. EVIDENCE: The provider stated that four staff had been recruited to work at the home once service users had been identified for admission. These staff are working in other employment at present. The provider was able to evidence that the recruitment procedure was implemented and employment files sampled included CRB (Criminal Records Bureau) written references and employment history for prospective staff. A copy of the induction-training programme for staff was seen. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 15 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): 38, and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The arrangements for the management of the home and the promotion of health and safety are satisfactory. EVIDENCE: The registered manager for the service resigned his post in March 2006 having never worked in the home due to it been unoccupied. The provider who is also the responsible individual has now applied to The Commission for Social Care Inspection to become the registered manager for the home. He is a qualified nurse with an RNMH qualification and considerable experience in management. He is currently managing an acute assessment and treatment unit for service users with a challenging behaviour. There is a health and safety manual in place, which includes a wide range of policies and procedures to promote health and safety within the home. Certificates were seen to confirm gas, electricity, water and central heating safety checks. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 16 The procedures for fire safety are in line with the fire safety officer’s recommendations and a copy of the certificate was given to the inspector for information. Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 17 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 3 2 3 3 X 4 3 5 3 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 3 25 X 26 3 27 3 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X X 3 X X X 3 X Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 18 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 YA20 Regulation 13 Timescale for action The registered person shall make 27/05/06 arrangements for the safe keeping of medicines in the care home and must provide a locked secure cabinet for this purpose. 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. Refer to Standard Good Practice Recommendations Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Prosignia Ltd DS0000065332.V291284.R01.S.doc Version 5.1 Page 20 - 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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