Inspection on 05/03/07 for Unicorn House (16)

This inspection was carried out on 5th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Unicorn House (16) 30/05/08

Unicorn House (16) 10/12/07

Unicorn House (16) 18/06/07

Unicorn House (16) 27/06/06

Unicorn House (16) 08/11/05

Unicorn House (16) 18/04/05

Unicorn House (16) 06/10/04

Unicorn House (16) 01/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Unicorn House (16) 16 Campden Road South Croydon Surrey CR2 7EN Lead Inspector James O`Hara Key Unannounced Inspection 5th March 2007 08:00 Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 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 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 Post Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified service users over the age of 65 to be accommodated until such time as the needs of the service users can no longer be met or until such time as the placements cease. No new service user with a mental health condition may be admitted to the home. A variation has been granted to allow two specified service users with physical disabilities to be accommodated at Unicorn House until such time as the service users can no longer be met or until such time as the placements cease. 27th June 2006 2. 3. Date of last inspection 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. 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) DS0000025864.V332384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key unannounced site visit at the home this inspection year. The first key inspection was completed on the 27th of June 2006. Random unannounced inspections were carried out at the home on the 12th of April 2006, 17th of May 2006 and the 20th 0f September 2006. This report includes information from some of these inspections. This unannounced visit took place between 8.00am and 4.00pm on a Monday morning. Methods of inspection included a tour of the premises and discussion with some of service users, the acting home manager Mr Jay Venkaya and the Deputy Manager Ms Nishi Mungra. Records examined included service users person centred plans, care plans, risk assessments, complaints, adult protection, staffing training, medication, and health and safety records. Requirements and recommendations from the previous inspections were also discussed with Mr Venkaya and Ms Mungra. What the service does well: What has improved since the last inspection? What they could do better: There have been numerous requirements set at previous inspections in relation to the home’s Statement of Purpose. The Statement of Purpose has not been Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 6 and continues not to be an accurate reflection of the services provided at Unicorn House. This could be misleading to those people seeking a placement with the home. The Registered Provider and Manager need to once again revisit and review this document so that it is an accurate representation of the service provided by the home. More work needs to undertaken with residents in order that they can have greater opportunities to choose their activities and holidays. The staff need continuing support by the managers within the home to consolidate their understanding of adult protection procedures and practice. A full time manager needs to be appointed and registered with the Commission. Regular monthly monitoring visits and quality assurance systems involving resident’s feedback need to be established and maintained. The inspectors would like to thank the residents, management and staff for their 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. The summary of this inspection report can be made available in other formats on request. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 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 (16) DS0000025864.V332384.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who may wish to use the service cannot be confident that their needs can be met as the Statement of Purpose continues not to be an accurate reflection of the services provided at Unicorn House. EVIDENCE: Three service users have moved out of the home since the last inspection. Two service users placements were terminated because their care managers assessed that the home was not meeting their needs. No new service user has moved into the home since the last inspection. At the inspection of 27th of June 2006 a requirement was set that the Proprietor must contact the care manager of a service user in order to verify that they were suitably placed in the home. The deputy manager confirmed that the care manager had reviewed the placement but had yet to send the report to the home. It is recommended that the home manager contacts all service users care managers and request copies of their most recent care plan/needs Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 9 assessments/placement reviews so that they can be kept on the service users file. A requirement was set at the last key inspection that the management of the home must write to the placing authorities of the two residents with disabilities to review their needs as the home was not registered for this category. This has now been done, which resulted in the home manager applying to the Commission for a variation to accommodate them. This has now been agreed. It was recommended at the inspection on the 20th of September 2006 that the homes Statement of Purpose be reviewed and include only information that was accurate and appropriate. It is important that those who wish to seek placements in this service have a clear understanding of what client groups the home’s staff are qualified and experienced to support and provide services to. The aim of the Statement of Purpose and inspection reports is to assist them to make informed decisions. There continues to uncertainty in this area which may have led to the last resident being admitted to Unicorn House at short notice from the previous placement. The care managers and NHS professionals then had to reassess the person in order to confirm that the placement was satisfactory. Staff in the home then needed specific training in order to properly understand the person’s current and future needs. In order that there is no further misunderstandings, those staff who assess prospective residents should be mindful of the registration category of the home and the Statement of Purpose when dealing with care managers who are seeking placements. In this context the Statement of Purpose needs to be revised to remove the reference to ‘associated mental health problems as there is a condition placed on the home that no one in this category should be admitted. It was recommended at the inspection on the 20th of September 2006 that the partnership arrangements with the British Institute of Learning Disabilities (BILD) be clarified. This was in order that it removed any confusion that BILD had an active role in the operations of the home. An action plan sent to the CSCI on 8th December 2006 stated that the reference to BILD related to Mr. Madhewoo (the proprietor) having received accreditation from BILD to train staff in non violent crisis intervention. In order to remove any confusion the word partnership should be removed. Other matters were also requested to be reviewed and clarified in the Statement of Purpose included the qualifications of the proprietor and resident’s choice of GP. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 10 The homes Statement of Purpose must be reviewed and be an accurate representation of the service provided by the home. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Person Centred Plans have not been updated which means that residents cannot be confident that their assessed and changing needs will continue to be met. Residents cannot be sure that they will be supported in decisions to take risks unless they are fully involved with their Person Centred Planning and risk assessments. EVIDENCE: Three service user personal files were sampled at random. Service user’s files included a resident’s profile, a missing person profile, full risk assessments and Person Centred Plans. Person Centred Plans include a relationship circle, my likes and dislikes, personal care needs, physical health needs, mental health needs, my dreams Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 12 and aspirations, social and spiritual needs and a section on the service users needs, goals, implementation and review. One service user had their Person Centred Plan reviewed in October 2006 and a review date has been set for April 2007. The other two service users Person Centred Plans had last been reviewed in April 2006 but had not been reviewed at the set date for October 2006. The deputy manager was of the view that care managers needed to be present in order for the reviews to be undertaken. However she was asked to discuss this with Croydon Councils Person Centred Planning co-ordinator who was to visit the home on the 8th of March 2007. All service users files include a full risk assessment. These risk assessments had last been reviewed on the 20/04/06. It is recommended that all service users risk assessments are reviewed and updated on a regular basis. The risk assessment format includes the statement “this is to certify that I have been involved while discussing the risk I pose to myself, the environment and other people under different circumstances, the contents have been explained to me and I understand” It was noted that the risk assessments had been signed and agreed by the registered provider and the service users key worker but not the service users. It is recommended that if appropriate service users agree and sign their risk assessments. Service user files also included service user comment forms, evidence of regular health care appointments and management guidelines for staff to follow in order to support service users with daily living skills. It was noted that the service user comment forms had last been completed for the period August 2005 to March 2006. So that the home can gain feedback about the quality of service provided in the home it is recommended that the home manager offer service users the opportunity to complete a service user comment form. A requirement was set at the inspection on the 27/06/06 that the Proprietor contact the service user’s care manager in order to review the service user plan to focus less on aggressive behaviour and more on positive reinforcements. It was unclear whether this approach was beginning to make any impact as an incident occurred early in October 2006 involving this resident which resulted in another resident sustaining a broken hip and being admitted to hospital. The placing authority terminated the placement prior to the person’s discharge from hospital. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 13 Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are being involved in the broader community and participating in a wider range of social activities. However this needs to be sustained before they can be confident that this can be is a regular expectation. EVIDENCE: A previous requirement was set that the registered manager must record evidence of activities attended by service users other than that provided by the Unicorn Workshop and Unicorn Training Institute. This has improved and needs to be sustained before it can be recognised as achieving a good standard. The home employs the Keeping Track Participation format for recording service users activities in the home and in the community. Activities are recorded on a weekly basis then archived. This format appears to work well for some of the Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 15 more active service users but for those service users who choose not partake in activities most of the record is blank. The deputy manager said that she recognised the need to develop a more appropriate activities record for individual residents. The deputy manager is developing this at present. During the Key inspection and subsequent random visits to the home it was noted that one particular resident was for the most part in bed or in his room. The deputy manager had stated that this was because the resident had expressed a wish to do so and would usually get up later in the day for a short time occasionally to go out. The acting home manager stated that this resident recently attended a horseracing meeting and has also started to go to the pub to watch football. During the conversation the deputy manager agreed to contact Crystal Palace Football Club for advice on obtaining a disabled persons season ticket. A number of residents went on a holiday to Mauritius last year. Concerns have been raised by care managers in respect of the residents having opportunities to select other holiday venues and different types of holiday closer to home. They were also concerned that they were not involved in any discussions about these holidays until after all the arrangements had been made. It is recommended that key people in the resident’s lives (including care managers) are notified as soon as practicable when decisions are being made about residents travelling abroad. It was observed that residents appeared comfortable and confident in their surroundings. One resident stated that she had been home for her father’s birthday and stayed for the weekend. She said that she had no plans to go out that day and would remain at the home. Another service user said that she planned to go for a drive and went out later in the afternoon. Records in the home indicated that residents have had opportunities for monthly trips out however activities during the day are still focussed on the Unicorn Day Service. With the developing Person Centred Planning focus it is hoped that residents can be more involved and supported in the community to increase their leisure and recreational activities. There has been a reduction in the level of unnecessary callers to the resident’s home since the proprietor has moved from the premises. Food is stored in a fridge and a fridge freezer just off the kitchen and a freezer in the basement. Tinned food is also stored in a room in the basement. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 16 Following a previous recommended that the home purchase fresh fruit and fresh vegetables on a more frequent basis the acting home manager stated that fresh fruit and vegetables are purchased at least three times a week. Menus were checked. The deputy manager stated that service users are offered a choice of meals and the record is completed for individuals after they have eaten; records indicate the choice meals and what service users chose. The deputy manager provided evidence that the task of preparing/developing a menu chart has been delegated to a member of staff. The acting home manager stated that service users meetings are held monthly. It was requested that he advise the inspector of the date of the next meeting and enquire if the service users would mind if the inspector attended. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the residents can be assured that they receive support in the way they prefer and require and that they will be protected by the home’s policies and procedures. EVIDENCE: Person Centred Plans include details on individual service users personal care needs, physical health needs and mental health needs. Service user files also included evidence of regular health care appointments and management guidelines for staff to follow in order to support service users with health care needs and challenging behaviour. There are no residents currently who have been assessed as able to self medicate. Medication is stored in a locked cabinet in the office. Medication administration records were checked on the day of the inspection. It was observed that on the 19th of February 2007 a member of staff had signed the medication administration record indicating that medication had been administered to a Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 18 service user when in fact the medication remained in the blister pack. The deputy manager was able to identify the member of staff responsible and the actions she would be taking to deal with this issue. However the acting home manager must ensure that all staff is aware of the home’s policies and procedures for handling medicines so as to ensure that the service users are so far as reasonably practicable protected from harm. All other records were up to date and accurate. The home has the support of a Boots pharmacist who visits on a six monthly basis to offer advice. The home also has a book for recording receipts of medication and a book for recording returns of medication. However, it is recommended that the pharmacist stamp the returns of medication book on the date when medication is returned. The acting home manager stated that the home has purchased a new medication storage cupboard for the home. This will soon be installed in the office. Conversations were had with three residents about their views of living in the home. There were all generally happy about the services provided and their day-to-day lives. Significantly, they implied that there had been a positive change in atmosphere since one particular resident had left the home. This observation was also confirmed by staff. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents cannot be confident that they will be protected from financial or physical abuse until all staff understands their responsibilities to protect them and follow the Vulnerable Adult Protection Procedures of the Local Authority. EVIDENCE: The home has a complaints procedure included in the Service Users Guide. The complaints procedure is available in widget and text and states that all complaints will be responded to in an efficient, effective and fair manner and were possible within 28 days. Service users are advised that they can raise their concerns with staff, their key worker, their care manager or the home manager. Service users are also advised that they can contact the Commission For Social Care Inspection and a telephone number is included. Since the last inspection two statutory notices have been served on the home on the 12th July 2006 and 10th August both as a result of a failure to notify the Commission of events in home that adversely affected the well being or safety of a service user. Both incidents were in the past during the period when the proprietor was covering the home and there was no registered manager. The incidents also involved Safeguarding Adults meetings being held and a police investigation of one of them which has resulted in charges being brought against resident who has since moved from the home. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 20 There have been a number of issues relating to how decisions have been made by the appointee about the personal finance and benefits of the residents. This has resulted in the placing authorities reverting back to being the appointees for their residents. Staff has received training in the Local Authority Vulnerable Adults procedures. However their understanding of this will be monitored at future inspections. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. In general the service users bedrooms were in good decorative order and had appropriate furnishing. The home was clean and free from offensive odours throughout. EVIDENCE: It was noted during a tour of the premises that the service users bedrooms were reasonably decorated and had appropriate furnishings, clean and free from offensive odours. Since the last inspection the registered provider has moved out of the top floor of the home. The acting home manager stated that work is under way to redecorate and furnish this part of the home and use it to support service users with cooking and independent living skills. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally there is greater clarity in the staff roles and responsibilities and residents are beginning to benefit as staff are more supported, supervised and trained. Recruitment practices have improved but residents cannot be confident that they can be supported and protected until good recruitment practice has been consolidated and a registered manager is in place. EVIDENCE: There is currently no registered manager at Unicorn House. Mr Jay Venkaya is providing the day-to-day management cover for the service on a part time basis. The Deputy Manager covers the other periods. The post of manager had been offered to a candidate, however this had yet to finally confirmed. The home has been without a manager for almost a year and whilst the current management arrangements have provided an acceptable interim model, it is imperative that a full time manager is in place and registered by the Commission. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 23 The staff team at the time of the inspection consisted of four part time and 7 full time care staff. All the part time staff are students, some of whom have limitations on the hours they are permitted to work. The staff roster indicates that the students work three shifts per week. At the previous inspection it was noted that due to staff retention problems Mr Madhewoo had increasing come to rely on non British National staff from within and outside the expanded EEC. This resulted in the Commission raising concerns about how quickly these staff could acquire a knowledge and understanding of the culture in which the service users had been predominantly raised. The profile of the staff remains very similar despite recruitment programmes undertaken by the Acting Manager. However, the majority of the staff team have now been together for over two years. The Acting Manager had also undertaken an exercise of reviewing all the staff who were used as relief workers on shifts and whether they were prepared to continue in that role. This has resulted in a reduction in the number of bank staff and provided more consistency in staffing for the residents. Staff are supervised by either the Acting Manager or Deputy Manager. A sample of training records were seen and these were up to date. The majority of the training has been provided by the Unicorn Services own training centre, which is located nearby. Staffing records for new staff were checked and found to have the appropriate documents and staffing checks. The service has brought in the services of an external Human Resources Agency who have been providing current good practice guidance and documentation for all the staffing issues and functions. One of the residents said that she has been involved in the recruitment procedures for staff. This is a commendable development that needs to be developed and maintained. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents cannot yet be assured that they are benefiting from a well run home until there is a permanent Manager in place who will involve the residents and their views in the development of their home. EVIDENCE: At the last Key Inspection, the Registered Provider was reminded to ensure that regular independent monthly visits to the home needed to be undertaken to assess the quality of service. As this did not happen a warning letter was sent to the registered provider in January 2007. A warning letter is an element of the Commission’s enforcement procedures. Since that date reports of the independent visits have been received by the Commission for January and February 2007. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 25 The management of the home are expected to seek feedback from residents. In the home’s Statement of Purpose they confirm that this is undertaken. However this has not been carried out since March 2006. It is recommended that the home manager seek the views of the service users families, advocates and care managers about the standard of care provided at the home and how these can be improved further. The appointment of Mr Venkara as the Acting Manager has resulted in improvements in the way the home is being managed. However Mr Venkara also has a full time job with the NHS and is only part time in the home. It is hoped that there will be a transitional period to allow the new manager a proper induction programme. Mr Venkara and the management team have introduced a different style of management within the home that has encouraged the staff to develop. However the improvements need to be observably sustained and the benefits to the residents need to be clear and measurable before the Commission can confidently assess the service as improving. The challenge for the management team will be the introduction of robust and verifiable quality assurance system in order to improve and develop the service. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 26 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 2 2 2 3 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 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 3 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 27 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 YA20 Regulation 18 (1) c Requirement All staff must be made aware of the home’s policies and procedures for handling medicines so as to ensure that the service users are so far as reasonably practicable protected from harm. Timescale for action 31/05/07 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 YA2 Good Practice Recommendations It is recommended that the home manager contacts all service users care managers and request copies of their most recent care plan/needs assessments/placement reviews so that they can be kept on the service users file. It is recommended that all service users risk assessments are reviewed and updated on a regular basis. It is recommended that if appropriate service users agree and sign their risk assessments. So that the home can gain feedback about the quality of service provided in the home it is recommended that the home manager offer service users the opportunity to DS0000025864.V332384.R01.S.doc Version 5.2 Page 28 2. 3. 4. YA9 YA9 YA39 Unicorn House (16) 5. YA14 6. 7. YA20 YA39 complete a service user comment form. It is recommended that key people in the resident’s lives (including care managers) are notified as soon as practicable when decisions are being made about residents travelling abroad. It is recommended that the pharmacist stamp the returns of medication book on the date when medication is returned. It is recommended that the home manager seek the views of the service users families, advocates and care managers about the standard of care provided at the home and how these can be improved further. Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Unicorn House (16) DS0000025864.V332384.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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