CARE HOME ADULTS 18-65
Unicorn House (16) 16 Campden Road South Croydon Surrey CR2 7EN Lead Inspector
James OHara Announced 18 & 19 April 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Unicorn House (16) Address 16 Campden Road South Croydon Surrey CR2 7EN 020 8688 1907 020 8686 0135 unicornprojects@hotmail.com Mr Maharajah Madhewoo Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vishul Seewoolall Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (12) of places Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: Unicorn House may admit service users who have a learning disability (Category LD) and service users with a learning disability who also have a diagnosed mental disorder (Category MD). Service users who do not have learning disability must not be admitted. Date of last inspection 06/10/04 Brief Description of the Service: Unicorn House is a twelve bedded home that is registered to provide care for service users who have a learning disability. At present there are ten service users living in the home. The location of the home is within easy reach of good public transport links and the centre of Croydon. This results in the service users being within easy reach of local amenities and services. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two days. The home was inspected under the National Minimum Standards Care Homes for Younger Adults. Methods of inspection included a tour of the premises formal and informal interviews with the homes management team, a number of service users and members of staff, an interview with a visiting care manager and a visiting district nurse. Comment cards returned to the Commission for Social Care Inspection as feedback from service users and their relatives were also used. Records examined included service user plans care manager needs assessments and risk assessments, medication records, complaints, staffing records, fire records. Evidence was gathered over a number of monitoring visits “Themed Visits” carried out over the last year in order to reduce the number of outstanding requirements and improve the service provided in the home. During these “Themed Visits” the inspector and the trainee manager Vishul Seewoolall (now the new registered manager) looked at various sections of the inspection document and set requirements with short timescales for action to be reviewed at each visit. “Themed Visits” took place on the 2nd July, 19th July 20th September 2004 (an unannounced inspection took place on the 6th October 2004) and 23rd February 2005 the inspector was also invited by the service users to attend a service user meeting on the 4th of February 2005. As a result of this approach the home has meet the vast majority of these outstanding requirements. What the service does well:
Service user plans (My Person Centred Plan) are comprehensive and service user led and service users families’ are invited to attend reviews. Communication and involvement by residents in making decisions about the home have been improved by holding monthly residents’ meetings with the residents Provides a variety of day care choices for residents. Some of whom said that they enjoyed going to the Unicorn Project and one service user said that she liked going to the Art Therapy Class at Geoffrey Harris House. All of the service users were spoken to over the two days of the inspection and in general most of their comments were positive. Service users comment cards returned to the Commission as feedback had comments such as: I’m happy, I like the steak and kidney pie, the staff socialise with me a lot, I like my privacy and being alone, its alright living here and I like going out for dinner, I like living here and I’d like to meet the inspector when he comes, it’s the happiest home in the whole world.
Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 6 A number of relatives comment cards were also returned to the Commission and one relative commented “My brother has been in care for a good many years, I do not think that he has been looked after or has been as comfortable as he has at Unicorn House”. What has improved since the last inspection? What they could do better:
There is a very high turnover of staff and the home relies heavily on Mauritian students and part time staff. A more balanced recruitment policy would contribute to providing a staff team that matched more closely the cultural mix of the residents. This in turn would increase their contribution to the assessment of need of the residents and provide them with more consistency. Since the last announced inspection in June 2004 five staff have left (including three staff dismissed two of whom were full time staff since the unannounced inspection in October 2004) and six staff have started work at the home. Twelve of seventeen of staff are Mauritian of which seven are students who work twenty hours a week. The new registered manager and the deputy manager have worked hard over the last twelve months to meet the National Minimum Standards but the lack of a permanent/full-time staff team has almost certainly undermined all their efforts to improve the quality of care in the home. The home must now move forward and develop a staff team with full time experienced staff in order to meet the needs of the service users.
Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 7 The home has made efforts to train staff but there is a constant need to pay for more repeated training because of the staff turnover. During a recent Adult Protection issue the home failed to follow Croydon Councils Protection of Vulnerable Adults and its own adult protection procedures correctly. It was agreed as one of the actions from the strategy meeting on the 1st February 2005 that the management of the home and all members of staff should be reintroduced to homes Adult Protection Policy and Croydon Councils Protection of Vulnerable Adults Procedure in order to ensure that the service users are safeguarded from abuse. This must now be followed up. Some service users said that sometimes late at night and early in the morning the doorbell rings late and this upsets them. At present the registered provider lives on the premises but plans to move out in the near future. The new registered manager and the registered provider must review the homes visitor policy and this should give guidance to people visiting the home late at night and early in the morning so as not to disturb the service users. The home has been set seven new requirements and seven recommendations. Requirements are centred round staffing issues, adult protection, and service users privacy. Recommendations are centred round administration, service user assessments and staffing. The new registered manager said that support from Commission for Social Care Inspection has been beneficial in guiding him to meet the previous requirements. To this end the inspector and the new registered manager have agreed to continue with the “themed visits”. The inspector would like to that the service users and their relatives for their help and feedback and staff and management of the home for their support on the day of the inspection. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 5. Prospective service users are now more able to make an informed choice about whether they wish to move to the home. They can also expect to have an assessment prior to their admission and a contract issued to them about the services they can expect to receive when they move in. EVIDENCE: The Statement of Purpose and Statement of Purpose have recently been updated and passed to service users. A needs assessment was carried out by a care manager prior to a new service user moving into the home in August 2004. Each service user has a contract. These have been developed using the National Minimum Standards as guidance and changes made are included in the Statement of Purpose and the Service User Guide. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. The service users can be confident that their individual plans (My Person Centred Plan) include all the essential information necessary to meet their needs. They can also be assured that they will be involved in making decisions that affect their day to day living. Service users have regular monthly service user meetings which allows them to be consulted and take part in decision making about how the home is run. EVIDENCE: All service user files include a My Person Centred Plan, completed risk assessments and the majority service users have had annual needs assessments carried out by care managers. The plans include the assessed and changing needs and aspirations of the service users. Service users have been involved in the recruitment and selection process. An interview form indicated that two service users were present as part of the interview panel. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 11 The inspector recently attended a service user meeting. Service users seemed comfortable and confident enough to speak and make their wishes known some service users where encouraged to take part. The inspector examined five service user files, the files included up to date risk assessments. The inspector was able to speak to a care manager who visited the home on the day of the inspection. He informed the inspector that the staff were pleasant and there were plenty of them, he liked the set up and the lay out. His only concern was that staff lacked training to meet his service users needs (Aspergers and Mental Health). The new registered manager showed the inspector evidence that the staff team is due to be trained on Aspergers in June and Mental Health in August. Staff are also to have training on Person Centred Planning at the end of this week. See staffing. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 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 standard(s) 11, 12, 13, 14, 15, 16 and 17. Residents continue to engage in appropriate leisure, age, peer and cultural activities and now also have the opportunity to attend daycentres and clubs outside the Unicorn Day Care Project which increases their inclusion into the broader community. The residents were not always satisfied with choice of food or options available which could have a negative impact on their health and well being. EVIDENCE: On the day of the inspection the inspector was invited to visit the Unicorn Project Day Centre. Activities have improved in that service users have opportunities to attend day services other that the Unicorn Project Day Centre. The new registered manager provided evidence that some service users attend Mencap Clubs i.e. the St Mary’s Club and the Sports Club. One service user regularly attends Art Therapy at Geoffrey Harris House and some service users attend the Croham Road Lunch Club. The home also holds a regular in house disco where a
Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 13 professional DJ is hired. Records show that six service users attend a local Church every Sunday. The homes Right Track records indicate all activities attended by service users however not specifically those outside of the Unicorn Project. It is recommended that the home records all activities attended by service users naming the clubs and daycentres attended. Service users said that they enjoyed the Unicorn project. One service user said that she liked going to the Art Therapy Class. Some service users said that sometimes late at night and early in the morning the doorbell rings late and this upsets them. At present the registered provider lives on the premises and these are his visitors. However these disturbances may end as the proprietor has plans to move out in the near future. The new registered manager and the registered provider must review the homes visitor policy and this should give guidance to people visiting the home late at night and early in the morning so as not to disturb the residents. Service users comment cards sent to the Commission for Social Care Inspection as feedback had comments such as: I’m happy, I like the steak and kidney pie, the staff socialise with me a lot, I like my privacy and being alone, its alright living here and I like going out for dinner, I like living here and I’d like to meet the inspector when he comes, it’s the happiest home in the whole world. Other comments include some staff don’t knock the door and sometimes I don’t like the food. The new registered manager must ensure that service users privacy and dignity is discussed at the next team meeting. The new registered manager should discuss what food is on the menu with all of the service users. A number of relatives comment cards sent to the Commission for Social Care Inspection as feedback had comments such as: My brother has been in care for a good many years, I do not think that he has been looked after or has been as comfortable as he has at Unicorn House. All comment cards indicated that relatives are satisfied with the overall care provided in the home. Also living at the home are pets belonging to some of the service users these include a dog, a cat, a budgie and three parakeets the home also has a fish tank with terrapins. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 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 standard(s) 19 and 20. All service users are registered with a General Practitioner and service users with Mental Health conditions attend a Psychiatric Clinic thus ensuring that their physical and emotional and mental health needs are met. The home has appropriate policies and procedures in place in respect of assessing service users abilities to self medicate. EVIDENCE: On the day of the inspection a service user asked the inspector if he could get her wheelchair sorted out, during a previous themed visit to the home the inspector recommended that the deputy manager contact the duty care manager for advice on accessing an occupational therapist visit to the service user who uses a wheelchair. The deputy manager had contacted the service users General Practitioner and a referral has been made to the occupational therapist regarding a wheelchair assessment. On the day of the inspection the deputy manager contacted the duty care manager who advised her to contact the General Practitioner to find out when the service user will be assessed. The inspector recommends that the deputy manager follow up the General Practitioners referral for the service user needing an assessment for her wheelchair. The registered manager said that he recently changed the homes medication supply from Boots to a local pharmacist who supplied medication to the home in a blister pack system. The registered manager stated that he plans to
Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 15 return to the Boots system as he feels that the home was better supported on issues around medication. Medication is stored in a locked cabinet in the office, medication recording sheets were noted to be up to date and accurate, the home has a record of receipts and returns of medication, each service user has a section in the medication file with a recent photograph, a medication profile and an individual homely remedies list signed and agreed by the service user and a General Practitioner. None of the service users have been assessed as being able to retain and administer their own medication. The inspector recommends that the home complete a weekly medication stock check. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 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 standard(s) 22 and 23. The home has the appropriate adult protection policies and procedures in place but if these are not followed as prescribed it can put service users and staff at risk. The home has an appropriate complaints procedure but unless this is made available to the service users’ families and advocates this could undermine the confidence that the proprietor, manager and staff will listen to their views, concerns and complaints and act upon them in a fair manner. EVIDENCE: Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 17 The home has an a complaints procedure completed in both text and widget form for the benefit of all service users the procedure is located in the service users guide, the inspector noted that most of service users had a copy of the Service User Guide in their bedrooms. Relatives comment card returned to the Commission for Social Care Inspection as feedback indicated that some relatives were not aware of the homes complaints procedures. The inspector recommends that the registered manager send a copy of the homes complaints procedures to all of the service users’ relatives. The home failed to follow Croydon Councils Protection of Vulnerable Adults and its own Adult protection procedures correctly. It was agreed as one of the actions from the strategy meeting on the 1st February 2005 that the management of the home and all members of staff are reintroduced to homes Adult Protection Policy and Croydon Councils Protection of Vulnerable Adults Procedure in order to ensure that the service users are safeguarded from abuse. This was not followed up. The new registered manager must ensure that the management of the home and all members of staff are reintroduced to homes Adult Protection Policy and Croydon Councils Protection of Vulnerable Adults Procedure as soon as possible in order to ensure that the service users are safeguarded from abuse. The registered provider (at the time the person registered to manage the home) failed to attend or send an apology to the follow up adult protection meeting in line with the local AP protocols within Croydon. The adult protection protocols are important policies and practices and it is expected that all providers who offer a service within the London Borough of Croydon respect them. The inspector recommends that the new registered manager hold regular team building days to discuss any areas of were improvement is needed, concerns of management and staff are addressed and communication is improved. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 27 and 30. Many improvements have been made to the décor of the home and other works are ongoing which ensures that service users can be confident that they will continue to live in a homely comfortable and safe environment that suits their needs and lifesyles. EVIDENCE: Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 19 The upstairs bathroom has been completely refurbished. The downstairs shower room has benefited from the home’s cleaning programme and looks more presentable. A shower curtain has replaced one of the shower doors the door was removed because the service user that uses the shower is a wheelchair user and has difficulty entering and exiting the shower. This service user has recently had her bedroom redecorated and there are plans to install an en-suite bathroom. Work is now completed outside of this service users bedroom window so that the she has a view of the garden. There are plans to insert a doorway with access to the garden. Electric cable leads from the socket to a wall lamp have been removed. The downstairs bathroom has recently been redecorated. One service user who likes to keep her bedroom door open has had a magnetic release mechanism connected to the fire alarm system fitted to her door as recommended at the last inspection. The home offers a large comfortable lounge with ample seating including three settees and two armchairs a fish tank with terrapins. There is a dining area with four sets of tables and chairs. The home has a sun lounge with comfortable seating and coffee tables, a birdcage inhabited by one budgie and three parakeets. There is a smoking room and seating arranged outside for service users wishing to smoke. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 and 36. Service users cannot be confident that they are supported and protected by the recruitment practices of the proprietor and that the staff are competent, trained or qualified to meet their joint and individual needs. EVIDENCE: The new registered manager is aware of the need to recruit a more culturally diverse staff team that would reflect the cultural needs of the service users. He and the deputy manager have worked hard over the last twelve months to meet the National Minimum Standards but the lack of a permanent/full-time staff team will continue undermine all their efforts to improve the quality of care in the home. To this end he informed the inspector that he has contacted various local employment agencies in an effort to recruit permanent/fulltime/qualified/experienced staff to work at the home. There is a very high turnover of staff and the home relies heavily on Mauritian students and part time staff and this does not reflect the cultural mix, contribute to the assessed needs or offer consistency of approach to the service users. Since the last announced inspection in June 2004 five staff have left (including three staff dismissed two of whom were full time staff since the unannounced inspection in October 2004) and six staff have started work at the home. Twelve of seventeen of staff are Mauritian of which seven are students who work twenty hours a week.
Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 21 The new registered manager must ensure that the employment of any persons on a temporary basis in the home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs. The home has made efforts to train staff but there is a constant need to pay for more repeated training because of the staff turnover. Given that the Statement of Purpose indicates that the home will support service users with Learning Disabilities and associated Mental Health needs the inspector would recommends that the home employ a RMN and staff with similar mental health qualifications. In order that the management can monitor the appropriateness of the staff on duty on each shift the staff rota should contain the role of each member of staff i.e. Management, Part Time, Full Time or Student. The inspector examined staff supervision records there was evidence that staff receive regular supervision. Staff files contain all of the information as required in schedule 2 of the National Minimum Standards. The inspector spoke to two members of staff on the day of the inspection one full-time staff and one student. One member of staff who started work at the home nine months ago said that when she is on shift service users are always her main priority she felt that she was well supported by managers she was completing NVQ level 2 but was concerned that she had missed some training while away on holiday. She said that she would speak to the new registered manager about this. The other member of staff a student has been working in the home for three months said that he had been through the homes induction, that he enjoyed working with the service users, has had regular supervision and is completing NVQ level 2. The inspector requested that he speak to another member of staff on the premises but was informed by the new registered manager that the member of staff in question was not part of the homes staff team but one of the registered providers administration staff. All members of staff that work in the service users home and are in contact with vulnerable adults must have a Criminal Records Bureau Check. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39 and 42. Service users are beginning to benefit from the improved management regime put in place by the manager and deputy over the past twelve months. In order that service users can remain confident that this will be consolidated and continue to improve the main objective for the management team must be to create a permanent/full-time/qualified/experienced staff team. EVIDENCE: In consultation with the manager there have been a number of “themed visits” to the home over the last twelve months. The improvements in the home have illustrated the commitment and dedication of new registered manager to improving the quality of care in the home. As a result in many areas the home now meets the National Minimum Standards however there are still areas that need to be improved (staffing). Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 23 There is now in place a new Quality Monitoring System which includes relatives and service user questionnaires. A number of relative’s questionnaires were noted to contain positive feedback. The registered manager must inform the Commission for Social Care Inspection in writing when the home has been assessed meeting the recommendations set by from the London Fire and Emergency Planning Authority dated 24th March 2005. The registered provider is no longer in day to day charge of the care home he must now make arrangements for visits under regulation 26 to be carried out on a monthly basis. 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23
ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 24 25 26 Score 3 3 x
Version 1.20 Page 24 Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 x
Score 27 28 29 30
STAFFING 3 x x 3 Standard No 11 12 13 14 15 16 17 3 3 x 3 3 2 x Standard No 31 32 33 34 35 36 Score x x x 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 2 2 Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 25 No 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 16 Regulation 12 (4) a. Requirement The new registered manager and the registered provider must review the homes visitor policy this should give guidance to people visiting the home late at night and early in the morning so as not to disturb the service users. The new registered manager must ensure that service users privacy and dignity is discussed at the next team meeting. The registered manager must ensure that the management of the home and all members of staff are reintroduced to homes Adult Protection Policy and Croydon Councils Protection of Vulnerable Adults Procedure as soon as possible in order to ensure that the service users are safeguarded from abuse. The new registered manager must ensure that the employment of any persons on a temporary basis in the home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs. All members of staff that work in Timescale for action 31/07/05 2. 16 12 (4) a 31/07/05 3. 23 37 (1) g 31/07/05 4. 35 18 (1) b 31/07/05 5. 34 19 (1) b 31/07/05
Page 26 Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 the service users home and are in contact with vulnerable adults must have a Criminal Records Bureau Check. 6. 42 23 (4) The registered manager must inform the Commission for Social Care Inspection in writing when the home has been assessed meeting the recommendations set by from the London Fire and Emergency Planning Authority dated 24th March 2005. The registered provider must make arrangements for visits under regulation 26. 31/07/05 7. 43 26 (1) 31/07/05 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. 2. 3. 4. 5. Refer to Standard 12 19 20 22 23 Good Practice Recommendations The inspector recommends that the home records all activities attended by service users naming clubs and daycentres attended. The inspector recommends that the deputy manager follow up the General Practitioners referral for the service user needing an assessment for her wheelchair. The inspector recommends that the home complete a weekly medication stock check. The inspector recommends that the registered manager send a copy of the homes complaints procedures to all of the service users relatives. The inspector recommends that the new registered manager hold regular team building days to discuss any areas of were improvement is needed, concerns of management and staff are addressed and communication is improved. Given that the Statement of Purpose indicates that the home will support service users with Learning Disabilities and associated Mental Health needs the inspector would recommends that the home employ a RMN and staff with similar mental health qualifications.
G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 27 6. 32 Unicorn House (16) 7. 8. 31 Staff rota to contain the role of each member of staff i.e. Management, Part Time, Full Time or Student. Unicorn House (16) G53-G53 S25864 UnicornHouse16 V187166 180405 Stage 4.doc Version 1.20 Page 28 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
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